Dartmouth variations - looking back and looking forward
Looking Forward, Looking Back: Assessing Variations in Hospital Resource Use and Outcomes for Elderly Patients With Heart Failure
By Michael K. Ong, Carol M. Mangione, Patrick S. Romano, Qiong Zhou, Andrew D. Auerbach, Alein Chun, Bruce Davidson, Theodore G. Ganiats, Sheldon Greenfield, Michael A. Gropper, Shaista Malik, J. Thomas Rosenthal and José J. Escarce
Circulation - Journal of the American Heart Association
October 13, 2009
Background: Recent studies have found substantial variation in hospital resource use by expired Medicare beneficiaries with chronic illnesses. By analyzing only expired patients, these studies cannot identify differences across hospitals in health outcomes like mortality. This study examines the association between mortality and resource use at the hospital level, when all Medicare beneficiaries hospitalized for heart failure are examined.
Methods and Results: (Warning: This section is technical and you may want to skip it for now.) A total of 3999 individuals hospitalized with a principal diagnosis of heart failure at 6 California teaching hospitals between January 1, 2001, and June 30, 2005, were analyzed with multivariate risk-adjustment models for total hospital days, total hospital direct costs, and mortality within 180-days after initial admission (“Looking Forward”). A subset of 1639 individuals who died during the study period were analyzed with multivariate risk-adjustment models for total hospital days and total hospital direct costs within 180-days before death (“Looking Back”). “Looking Forward” risk-adjusted hospital means ranged from 17.0% to 26.0% for mortality, 7.8 to 14.9 days for total hospital days, and 0.66 to 1.30 times the mean value for indexed total direct costs. Spearman rank correlation coefficients were 0.68 between mortality and hospital days, and 0.93 between mortality and indexed total direct costs. “Looking Back” risk-adjusted hospital means ranged from 9.1 to 21.7 days for total hospital days and 0.91 to 1.79 times the mean value for indexed total direct costs. Variation in resource use site ranks between expired and all individuals were attributable to insignificant differences.
Conclusions: California teaching hospitals that used more resources caring for patients hospitalized for heart failure had lower mortality rates. Focusing only on expired individuals may overlook mortality variation as well as associations between greater resource use and lower mortality. Reporting values without identifying significant differences may result in incorrect assumption of true differences.
WHAT IS KNOWN
- Substantial variation has been documented among hospitals in the resources used to care for elderly Medicare beneficiaries with chronic illnesses during the last 6 months of life.
- By only including individuals who have died in the analyses, researchers cannot identify differences on health outcomes such as survival.
WHAT THE STUDY ADDS
- This study found variation among California teaching hospitals in survival for patients hospitalized with heart failure. This variation would have been overlooked by a study that only examined heart failure patients who died.
- When analyzing all patients hospitalized for heart failure, California teaching hospitals that used more resources had lower mortality rates.
- When analyzing all patients hospitalized for heart failure, the variation in resource use among California teaching hospitals was 27% to 44% less than the variation observed when analyzing only heart failure patients who died.
http://circoutcomes.ahajournals.org/cgi/rapidpdf/CIRCOUTCOMES.108.825612v1.pdf
Comment:
By Don McCanne, MD
As the nation attempts to identify ways of slowing the excessive growth in our health care costs, it is only natural that we would look at the great variability in health care spending that does not seem to correlate with health care outcomes. John Wennberg and his colleagues, in producing the Dartmouth Atlas, have confirmed that these variations are very real, though more recent refinements have demonstrated that the differences are not quite as great when corrected for other factors.
A prior study of California hospitals showed that these differences were not limited to those areas for which there seems to be an easier explanation (private hospitals with a liberal supply of high-tech services and professionals treating wealthier patients versus under-budgeted safety-net institutions treating low-income patients), but these Dartmouth differences were also noted between the various University of California teaching hospitals, which have similar funding, staffing and equipment.
This new study looked closer at the differences between the University of California teaching hospitals (including one private teaching hospital affiliated with UCLA). The authors showed that looking back for six months at patients who had died of heart failure did confirm the differences, although not as great since more variables were considered. Higher spending did not improve outcomes for the obvious reason that patients were selected for study on the basis of a common outcome - death.
The important contribution of this study is that they selected the same disorder as used in the death study - congestive heart failure - and looked forward for six months for the outcome of survival or death. This study showed that the teaching hospitals using more resources (spending more money) had a lower incidence of death.
Okay. Now, what care are we going to refuse to fund? Just looking at congestive heart failure alone, it is going to be very difficult to sort out the details to determine which interventions are of value and which are not. Now think of the task of sorting out these differences for all other serious disorders.
So how do we select out those services that should be eliminated from coverage? Legislators and bureaucrats certainly understand that they are not up to the task, so what do they recommend? They are suggesting that we lower spending by paying only for efficient care (i.e., by paying less money), by bundling payments and using accountable care organizations. Third party payers would distribute the funds while health care professionals would micromanage the use of those funds.
Think of the logistical nightmare of contracting with all the services and facilities that would be required in an accountable care organization. Even just informally gathering these services together to accept a bundled payment would entail similar logistical barriers. But then think of the internal conflicts that would occur when it comes time to decide how to divide up the spoils. The micromanagement within these entities would not be based on projected optimal outcomes, but they would be based on pecuniary interests.
If high-quality teaching institutions within the same university system are having difficulties fine tuning health care, how could we ever expect all facilities throughout the nation to adhere to the highest standards when they aren’t even understood?
Although we can continue to study the differences and educate professionals on better practices, we can’t really look to the Dartmouth variations as a quick source of cost savings to finance our other health care needs.
But there is one quick measure that would provide a great start for achieving a higher-value health care system. Get rid of the private insurers and establish an improved Medicare system that would include all of us. That would save about $4 trillion in the next ten years that could be used on actual health care, without increasing our national budget deficit. With a single financing system, we would then be able to make some gradual headway with the Dartmouth variations.