Practice Pattern Variation
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At the risk of overstaying my welcome on this subject, I thought I might comment on a recent story in the New York Times concerning practice pattern variation and the Wennberg guys at Dartmouth. The Times article — published on May 30th — focused on the fact that the resource use for elderly patients during the last two years of life in some New York City hospitals varied enormously from the resource use in other New York City hospitals. Private teaching hospitals, like NYU, landed in the 99th percentile nationally in terms of resource use during the last two years of life for patients living with at least one of nine chronic conditions, while Bellevue Hospital Center ended up in the 60th percentile. This was still above the national average (50th percentile), but much lower than NYU. The difference is not insignificant. The resource variation over that two year period between the 99th percentile and the 60th percentile is 25%.
And before everyone concludes that more is better, it’s worth pointing out that the Mayo Clinic — one of the world’s pre-eminent health care delivery systems — finished in the 28th percentile nationally in the same study. Dr. David Goodman, a co-author of the study said, “The general principle is that greater intensity of care is not better, and at the high end can actually be harmful.”
So why such a big difference? Some of it might have to do with having richer, better educated, more demanding patients and patient families at NYU than at Bellevue — which serves a lower income population. But this doesn’t explain the Mayo Clinic difference. Dr. Eric Manheimer, who is the Medical Director at Bellevue and on the faculty at NYU, said he thought it was something else. He said he thought Bellevue doctors spent less because 75-85 percent of them are on salary (much like Mayo), and therefore, have little incentive to order tests or other interventions. “You end up with the phenomenon of specialists referring to other specialists, with nobody coordinating, which results in confused messages, more referrals, more hospitalizations, deterioration in health care and a more anxious patient…We’re not any smarter or better than the private doctors. But when you have a salaried physician staff that’s cohesive, that works together, with no incentive to do additional health care, that a different mental model.”
The Dartmouth Atlas data shows similar differences in Massachusetts. Boston hospitals and physicians finished in the 66th percentile overall, while Worcester finished in the 44th percentile, and Springfield in the 37th. Within Boston’s teaching hospital community, Mass. General ranked at the 82nd percentile, Brigham and Women’s at the 70th percentile, and Beth Israel Deaconess at the 61st percentile, while Boston Medical Center and Lahey — with far more salaried docs than the other three — came in at the 50th and 46th percentile respectively. And since this study uses Medicare data, the price differences that exist among these institutions for private payors would be somewhat muted. While Medicare doesn’t pay everyone the same way for the same service, the spreads among teaching institutions would be much smaller. This variance is really driven by practice pattern and utilization variation.
Consumers Union, the folks who brought us Consumer Reports Magazine, find this all very interesting. The Times story referenced the fact that Consumers Union plans to add a hospital rating service to its traditional consumer services, and they plan to rely heavily on the Dartmouth Atlas work to make their index work. This is a welcome addition to the transparency movement.
Since Bellevue in NYC, with a large number of salaried doctors, still scored in the 60th percentile while the Mayo Clinic was in the 28th percentile, it suggests that the general practice pattern culture in NYC is considerably more aggressive than it is in Minnesota. Other things equal, one would also expect generally more aggressive treatment in teaching hospitals than in a community setting because the teaching hospitals have the capability to do more plus their need to educate the next generation of doctors provides an additional incentive to sometimes do things for the educational value even if it may not help the patient but (hopefully) won’t cause harm either.
My two conclusions from the fact that practice patterns vary widely in the U.S., especially with respect to end of life care are: (1) it is important for patients to execute living wills and advance directives, for family care givers to know where they are, and to make sure the hospital has it and includes it in the patient’s chart and (2) every hospital of any size should employ salaried palliative care specialists who can explain the options available to patients and families in end of life situations. Insurance company case managers, for their part, should do their best to make sure this happens and insurance companies themselves should reimburse palliative care specialists adequately even if Medicare doesn’t. I think it would be in their economic interest to do so.
Barry - don’t disagree with living wills and advance directives are a good idea, but would point out that somebody like RAND studied how often DNR orders are not honored by health care providers, and the percent was something like 50. In other words, about half the time, providers didn’t honor the DNR orders issued by their patients. We have a very long way to go on this one.
Hospice care is an unlimited benefit in all HPHC policies, for the reasons you outline above. Not true, I don’t think, for Medicare. At least not yet.
The non-honoring of DNR orders has much of its origin in two factors: lack of immediate availability of the DNR order when the patient is discovered in arrest, and fear of malpractice suits. Although the hospitals try to make DNR orders obvious in patient rooms, it can be seen as kind of insensitive to post them on the door or in other prominent places. No one has time to check the chart before calling the code, and often the code team does not work on the floor and doesn\\\’t know the patient. These are not excuses since they are remediable, just explanations. Also, often family members are not in agreement over DNR orders. I just wanted to point these features out to allay any ideas that DNR orders are deliberately ignored for no reason.
Bev - great post and a great set of insights. I’d be interested in your thoughts on whether or not medical professionals also feel under some obligation to “do something” for patients under duress. I’ve had many conversations with friends of mine who are clinicians about this issue, and find, more often than not, that they tend to lean, intrinsically, in the “do” direction, all other things being equal. I presume this is based on their line of work and their training. In other words, it’s hard for caregivers to start with a presumption against delivering care - even if that might be the patient’s preferred approach.
Charlie;
Yes, I think there is no question that doctors are trained to heal and therefore it is difficult to sit back and do nothing - once the code is called. As a practical matter, if the patient is a DNR a code shouldn’t have been called in the first place. This is usually a nursing issue and once again, they err on the side of caution unless the patient or family has made it crystal clear they really do mean DNR. It’s a difficult issue. I think having a palliative medicine service can help this issue, but I would defer to those with more experience than me on that part of it.