Less May Be More When Managing Patients With Severe Chronic Illness

Abstract

WHILE CONVENTIONAL WISdom states that care for older patients with chronic diseases is best performed by specialty physicians in acute care settings such as academic medical centers, a new report suggests otherwise. Researchers with the Center for the Evaluative Clinical Sciences at Dartmouth Medical School in Hanover, NH, reported that medical costs varied across the nation but that quality of care is not necessarily linked tohigher-cost care.For more than a decade, these researchers have been studying and issuing reports showing such variation, but this study shows for the first timedifferencesamong specific hospitals and their physician networks. These differences in cost, visits to specialists, days in the hospital, and use of intensive care beds exist after controlling for illness severity. The study, “The Care of Patients with Severe Chronic Illness: An Online Report on the Medicare Program by the Dartmouth Atlas Project,” released May 16, is available at http://www .dartmouthatlas.com/atlases/2006 _Chronic_Care_Atlas.pdf. Its findings reflect an examination of Medicare claims data from more than 4300 hospitals in 306 regions involving 4.7 million Medicare enrollees who died from 2000 to 2003 and who had at least 1 of 12 chronic illnesses. To assess quality of care, the researchers used several claims-based measures. One was the percentage of patients seeing 10 or more physicians, which shows the propensity for referral, with high scores possibly indicating a lack of continuity of care. Another noted the percent of deaths occurring during a hospitalization involving one or more stays in an intensive care unit. A stay in intensive care indicates aggressiveness of treatment for chronically ill patients, but the researchers noted other evidence that, overall, more aggressive care in managing patients with chronic illness does not lead to longer length or improved quality of life. Also, underuse of effective care in treatment for acute myocardial infarction, congestive heart failure, and pneumonia (as reported by the Hospital Quality Alliance) was used as an indicator of inadequate quality of care. These data suggest that more care as measured by the number of physicians visits or cost does not enhance quality of care, despite the fact that the US population “believes that more medical care means better care,” said Elliott S. Fisher, MD, professor of medicine and of community and family medicine at Dartmouth Medical School and one of the report’s coauthors. Such misperception results in a huge economic burden on the nation, where more than 90 million people have a chronic illness such as diabetes, cancer, and heart disease and about 70% of all deaths are caused by such illnesses. The care for these patients accounts for more than 75% of all US health care expenditures.