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CECS study calls for overhaul in treatment of chronic illness

According to Dartmouth Atlas of Health Care improving care could also lower costs

A new study by the Center for the Evaluative Clinical Sciences (CECS) at Dartmouth Medical School (DMS) uncovers staggering variations in how hospitals care for chronically ill elderly patients, indicating serious problems with quality of care and pointing towards unnecessary spending by Medicare. According to the study's authors, lower utilization of acute care, hospitals, and physician visits could actually lead to better results for patients and prolong the solvency of the Medicare program. The study calls for overhauling how the nation manages chronic illness, and proposes that hospitals take leadership in redesigning how they care for the chronically ill.

US Map
This map from the Dartmouth Atlas of Health Care illustrates regional variations in medical care for chronically ill Medicare patients. (Image courtesy of CECS)

Three issues drive the differences in the cost and quality of care, according to principal investigator and Peggy Y. Thomson Professor for Evaluative Clinical Sciences John E. Wennberg. "Variation is the result of an unmanaged supply of resources, limited evidence about what kind of care really contributes to the health and longevity of the chronically ill, and falsely optimistic assumptions about the benefits of more aggressive treatment of people who are severely ill with medical conditions that must be managed but can't be cured," he says.

The Dartmouth Atlas Project (DAP) studied the records of 4.7 million Medicare enrollees who died from 2000 to 2003 and had at least one of 12 chronic illnesses. The researchers studied patients with chronic illnesses because about 30 to 35 percent of Medicare dollars are spent on people with these conditions during the last two years of their lives. The study demonstrates that even within this limited patient population, Medicare could have realized substantial savings—$40 billion, or nearly one-third of what it spent for their care over the four years—if all U.S. hospitals practiced a low-cost/high-quality standard.

The DAP began in 1993 as a study of health care markets in the United States, measuring variations in health care resources and their utilization by geographic areas. More recently, the research agenda has expanded to reporting on the resources and utilization among patients at specific hospitals.

The new research is based on Medicare claims data for more than 4,300 hospitals in 306 regions, recently released in a new database.  For the first time, those who use, provide, pay for, and make policy about America's health care system will be able to compare the efficiency of states, regions, and their individual hospitals and associated physicians in treating patients with chronic illness.

A fundamental problem, and one that contributes to both overspending and worse outcomes, is that most acute care hospitals have become first-line providers of services to chronically ill elderly people, whose care would be better managed, safer, and less expensive outside the hospital setting, according to the DAP.
"The problem of overuse of acute care hospitals and medical specialists in the management of chronic illness is rapidly getting worse," says Wennberg. He points to findings that the resources per capita allocated to managing chronic illness during the last two years of life are increasing steadily each year. For example, the nation's health care providers were using 13.6 percent more intensive care unit (ICU) beds in 2003 than they did in 2000. Physician labor used to manage chronic illness also increased substantially: 13.4 percent for medical specialists and 7.7 percent for primary physicians. The acceleration was greatest in regions that were already using the most care, so the gap between high and low rate regions grew greater over the four years.

The financial incentives used by Medicare and most other payers encourage the overuse of acute care hospital services and the proliferation of medical specialists. The care of people with chronic illness accounts for more than 75 percent of all U.S. health care expenditures, indicating that overuse and overspending is not just a Medicare problem—the health care system as a whole has not developed efficient, effective ways of caring for people with severe chronic illnesses. The report calls for a reimbursement system that rewards, rather than penalizes, provider organizations that successfully reduce excessive use of services and develop broader strategies for managing their patients with chronic illness.

There are no recognized evidence-based guidelines for when to hospitalize, admit to intensive care, refer to medical specialists or, for most conditions, when to order diagnostic or imaging tests, for patients at given stages of a chronic illness.

Both doctors and patients generally believe that more services produce better outcomes. But, hospitals that treated patients more intensively and spent more Medicare dollars did not get better results. Similarly, the regions with the best quality and outcomes used fewer resources relative to their high-cost counterparts. Patients in low-cost, high-quality regions such as Salt Lake City, Utah, Rochester, Minn., and Portland, Ore., are admitted less frequently to hospitals, spend less time in intensive care units, and see fewer specialists.

"This carries an important implication for health care policy: Health care organizations serving these low-cost regions aren't withholding needed care," says coauthor Elliott S. Fisher, associate at the Veterans Affairs Outcomes Group and professor of medicine and of community and family medicine at DMS. "On the contrary, they are more efficient. They achieve equal and often better outcomes with fewer resources. These organizations offer a benchmark of performance toward which other systems should strive."

The report emphasizes the need for academic medical institutions and federal agencies, such as the National Institutes of Health (NIH), to do patient-level studies to produce detailed evidence defining the efficient clinical practices.

The study, and the DAP interactive database, was funded by the Robert Wood Johnson Foundation, in partnership with a funding consortium including the WellPoint Foundation, the Aetna Foundation, the United Health Foundation, and the California HealthCare Foundation. The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country and is the nation's largest philanthropy devoted exclusively to improving the health and health care of all Americans.

Questions or comments about this article? We welcome your feedback.

Last Updated: 12/17/08