[tt] NYT: Researchers Find Huge Variations in End-of-Life Treatment

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One problem with getting alarmed is that you most often don't know that 
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Researchers Find Huge Variations in End-of-Life Treatment
New York Times, 8.4.7
http://www.nytimes.com/2008/04/07/health/policy/07care.html

By ROBERT PEAR

WASHINGTON -- New research shows huge, unexplained variations in
the amount, intensity and cost of care provided to Medicare
patients with chronic illnesses at the nation's top academic
medical centers, raising the possibility that the government could
save large amounts of money.

In a report being issued on Monday, Dartmouth researchers say that
total Medicare spending in the last two years of life ranges from
an average of $93,842 for patients who receive most of their care
at U.C.L.A. Medical Center to $53,432 at the Mayo Clinic's main
teaching hospital in Rochester, Minn.

Other top-ranked hospitals fell in between. Medicare spending
averaged $85,729 for those who used Johns Hopkins Hospital in
Baltimore, $78,666 at Massachusetts General and $55,333 at the
Cleveland Clinic.

Differences in the last six months of life were even more striking.
Medicare spent an average of $52,911 for U.C.L.A. patients and
$28,763 for those who used the Mayo hospital, St. Marys.

The numbers, from the 2008 edition of The Dartmouth Atlas of Health
Care, have caught the eye of federal officials, who say Medicare
could save billions of dollars a year if doctors and hospitals in
high-spending regions were as efficient as those in low-spending
regions.

"How can the best medical care in the world cost twice as much as
the best medical care in the world?" asked Peter R. Orszag,
director of the Congressional Budget Office, referring to the
top-ranked hospitals.

More than 90 million Americans have chronic illnesses like
diabetes, cancer and heart disease, and 7 out of 10 die from
chronic diseases. Most of Medicare's spending on such patients in
the last two years of life is for care in hospitals.

Dr. John E. Wennberg of Dartmouth Medical School, the chief author
of the study, said doctors and hospitals that provided more care,
or more intensive care, did not necessarily achieve better results
for patients.

"Some chronically ill and dying Americans are receiving too much
care -- more than they and their families actually want or benefit
from," Dr. Wennberg said. "Contrary to popular assumptions, it's
the volume of services, not the price per service, that accounts
for most of the variation in Medicare spending."

The researchers analyzed data for more than 90 academic medical
centers and focused on five ranked as the nation's best by U.S.
News & World Report.

"The U.C.L.A. Medical Center was by far the most aggressive in
managing chronic illness, as measured by the use of medical
specialists and intensive care units, as well as the total number
of physician visits," the Dartmouth report said.

In the last six months of life, the Dartmouth researchers said,
chronically ill patients using the hospital at the University of
California, Los Angeles, spent about 50 percent more time
hospitalized and had more than twice as many doctor visits as those
who received most of their care at Mayo.

Hospital executives said they took the report seriously and wanted
to understand the disparities.

Dr. J. Thomas Rosenthal, chief medical officer at the U.C.L.A.
hospital, defended its practices.

"Some of the aggressive care saves lives," Dr. Rosenthal said. "The
Dartmouth study does not ferret that out in a systematic way."

Dr. Rosenthal also said that patients at U.C.L.A. might be more
severely ill than those at other academic medical centers.

The Dartmouth Atlas says Medicare spending was even higher,
averaging more than $105,000 per beneficiary, for those who
received care in the last two years of life at several other
hospitals, like Cedars-Sinai in Los Angeles and New York University
Medical Center in Manhattan.

Dr. Michael L. Langberg, chief medical officer at Cedars-Sinai,
said he was not entirely surprised. "We provide the highest volume
of high-intensity, complex care of any hospital on the West Coast,"
he said in an interview.

Dr. Langberg cited two limits of the Dartmouth study. The
researchers focused on patients who died, not those who lived, and
they did not have access to laboratory results or other clinical
information on patients.

Prof. Elliott S. Fisher of Dartmouth, a co-author of the study,
said those observations were correct. But he added: "We are
comparing patients with identical outcomes -- all were dead in two
years -- so it's unlikely that differences in the severity of
illness account for the variations we saw. In other studies, we
found no evidence that a higher-intensity pattern of care leads to
better survival. Some patients benefit, but just as many or more
may be harmed."

Dr. Denis A. Cortese, president of the Mayo Clinic, suggested
several reasons for his institution's less aggressive style of
care.

"Our physicians are all salaried," Dr. Cortese said. "They have no
financial incentive to do more than is necessary for the patient.
In each case, multiple doctors and nurses make decisions
collaboratively with the patient and family members. We really try
to understand the patient's wishes for end-of-life care."

Dr. Robert A. Press, the chief medical officer at N.Y.U. Medical
Center, said it was taking steps to address the findings. But he
said: "It's not an easy fix. We are dealing with a culture of
physicians who have been very aggressive in their care and a
patient population that has desired this type of care."