By Rebecca Adams, CQ HealthBeat Associate Editor
October 30, 2012 -- The type and amount of care that the top 23 academic medical centers give Medicare patients, particularly at the end of their lives, varies significantly, according to a new Dartmouth Atlas Project study.
The 24-page report used Dartmouth Atlas of Health Care data to analyze the differences in services that Medicare patients received at teaching hospitals, including academic medical centers rated by U.S. News and World Report as the best hospitals for clinical excellence in 2012-13. The hospitals are responsible for about 17 percent of all primary residency slots in 2012. The Dartmouth Atlas of Health Care uses Medicare data to understand variations in medical care across U.S. hospitals and regions.
"I was very surprised to see such dramatic variation," study co-author Anita Arora, a recent graduate of the Geisel School of Medicine at Dartmouth, said on a call with reporters. She said given that the institutions are considered among the best teaching hospitals in the country, she expected that they all would use evidence-based practices and would not show major differences in the way they treat patients.
The report includes information on care provided in the last six months of life, regional surgical procedure rates and quality measures on patients' experience that each hospital sends to the Department of Health and Human Services.
A main goal of the report, which was supported by the Robert Wood Johnson Foundation, was to inform medical students about the practices at academic centers where they plan to get further training. But officials who worked on the project told reporters that patients also might be interested in learning which institutions tend to provide more aggressive treatment.
Coauthor Alicia True told reporters that most patients would prefer to spend their final days in a home-like setting. But for many, True said, what happens isn't necessarily their preference but rather the practice style of the hospital where they receive their care. For instance, about half of chronically ill patients at Johns Hopkins Hospital in Baltimore were enrolled in hospice in their last six months of life, compared to about 23 percent of patients at Mount Sinai Medical Center in New York City. True said that a resident at Mount Sinai might see more aggressive care as the norm, with hospice a last resort, while a Johns Hopkins resident might be better trained in having discussions with patients about what they really want.
Another example the study authors cited is that patients are twice as likely to get knee replacement surgery in Salt Lake City, which had 11.9 per 1,000 discharges, than in Manhattan, which had 4.5 per 1,000 discharges. In New York, residents might be more likely to recommend physical therapy, the authors said.
The study authors said that more care is often not better care, and that residents who are trained at facilities that encourage more intensive care may adopt that style regardless of whether it leads to better outcomes.
"These variations in the way care is delivered are not trivial, as they may very well affect the future practice of medicine," said John R. Lumpkin, director of the Health Care Group at the Robert Wood Johnson Foundation, a longtime funder of the Dartmouth Atlas Project. "During their residency training, young physicians learn by observing faculty, making decisions on how aggressively to treat chronically ill patients at the end of life, and whether to recommend surgery when other treatment options exist."
David C. Goodman, co-principal investigator for the Dartmouth Atlas Project and director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice, said in a written statement that "These findings challenge the assumption that clinical science alone drives medical practice at these prestigious institutions and thus raise a serious issue for academic medicine. With such drastic variations from one institution to the next, they clearly cannot all be right."
Goodman told reporters that the data "reflect irrational differences" and that prestigious teaching hospitals in many places "fall short."