Use of hospitals, physician visits, and hospice care during last six months of life among cohorts loyal to highly respected hospitals in the
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《英国医生杂志》
1 Center for the Evaluative Clinical Sciences, Dartmouth Medical School, 7251 Strasenburgh, Hanover, NH 03755-3863, USA, 2 VA Outcomes Group, White River Junction, VT 05001, USA, 3 Institute for Clinical Evaluative Sciences, Toronto, Canada, 4 Dartmouth College, Hanover, NH 03755, USA
Correspondence to: J E Wennberg john.wennberg@Dartmouth.edu
Abstract
The frequency of use of hospitals, intensive care units, and physician visits among patients with chronic illness varies extensively across hospital regions in the United States, including regions served by well known academic medical centres. The variations are unrelated to population based measures of need but are closely associated with the per capita supply of hospital beds and physicians.1-4 The variations in frequency of use of these "supply sensitive" services during the last six months of life are particularly striking.1 These variations are of concern because they do not seem to reflect patients' preferences or rates of illness. Moreover, patients with chronic illnesses who live in regions with high rates of use do not seem to have better health outcomes.5-7 For these reasons, we have argued that the research agenda for academic medical centres should give high priority to comparative studies of their own patterns of practice with the goal of rationalising the management of chronically ill patients and answering questions about how many hospital beds and physicians are needed to provide optimal care.5 8 An important first step is to obtain population based performance measures specific to academic medical centres. In this paper, we document extensive variations in end of life care among cohorts of patients enrolled in Medicare who receive most of their inpatient care at well known academic medical centres in the United States.
Methods
Table 1 shows the characteristics of the study population. Of the 115 089 patients, 98 415 (85%) were chronically ill, many with two or more conditions. The intensity of care during the last six months of life and at the time of death varied substantially. The figure shows the standardised utilisation ratios and statistical measures of variation among the 77 hospital cohorts. Among the 77 hospital cohorts, the average number of days spent in hospital during the last six months of life was more than 27 days—almost a month—in the highest ranked cohort and fewer than 10 days in the lowest ranked cohort. Average ICU days varied by a factor of six, from 1.6 to 9.5 days per person; physician visits varied by a factor of four, from less than 18 to more than 76 visits per decedent. The propensity to use multiple physicians varied from less than 17% of patients seeing 10 or more physicians in the last six months of life to more than 58% of patients. The percentage of deaths occurring in hospital ranged from less than 16% to more than 55%; deaths associated with a stay in an intensive care unit varied from less than 9% to more than 36%. Enrolment in a hospice varied among the cohorts from less than 11% of decedents to more than 43%.
Table 1 Illness and demographic characteristics among patients assigned to 77 hospital cohorts. Values are numbers (percentages)
Distribution of rates and statistical measures of variation for end of life care among 77 cohorts assigned to hospitals with national reputations for high quality. ICU=intensive care unit
Table 2 examines the intensity of care during the last six months for cohorts loyal to major teaching hospitals located in metropolitan regions with two or more major teaching hospitals. They are ranked according to the (unweighted) average number of patient days per decedent. By this measure, the hospitals located in Manhattan provided the most care. Other regions with high hospital day rates included Los Angeles, Philadelphia, and Washington, DC. Patient cohorts loyal to the teaching hospitals in these regions also tended to have a higher frequency of physician visits, and a higher proportion saw 10 or more physicians. However, the use of intensive care units varied: the rates were high among the listed teaching hospital cohorts in Los Angeles, low in Washington, DC, and varied substantially according to specific hospital cohorts in Philadelphia and New York. Cohorts in Boston and St Louis exhibited considerable within area variation in hospital days and ICU days. By contrast, those in Minneapolis and San Francisco had low rates on all four measures of intensity of care in the last six months of life.
Table 2 Age, sex, race, and illness adjusted rates (95% confidence intervals) for hospital days, days in intensive care, and physician visits and percentage seeing 10 or more physicians during last six months of life among patient cohorts loyal to selected academic medical centres by region of location
The observed variation could have been generated by substitution between hospital use, physician visits, and hospice care. Enrolment in a hospice was inversely correlated with hospital days in the last six months of life (r = - 0.41; P < 0.0002), the chance of dying in a hospital (r = - 0.51; P < 0.0001), and the percentage of deaths occurring in association with a stay in the intensive care unit (r = - 0.28; P = 0.012). However, the percentage enrolled in a hospice was not correlated significantly (P > 0.05) with fewer physician visits, seeing 10 or more physicians, or ICU days in the last six months of life. We found a strong positive correlation between the number of days spent in hospital and the number of physician visits within the last six months of life (r = 0.77; P < 0.0001).
Discussion
Wennberg JE, Cooper MM, eds. The quality of medical care in the United States: a report on the Medicare program. The Dartmouth atlas of health care 1999. Chicago, IL: American Hospital Association Press, 1999.
Wennberg JE, Freeman JL, Culp WJ. Are hospital services rationed in New Haven or over-utilized in Boston? Lancet 1987;i: 1185-8.
Wennberg JE, Freeman JL, Shelton RM, Bubolz TA. Hospital use and mortality among Medicare beneficiaries in Boston and New Haven. N Engl J Med 1989;321: 1168-73.
Fisher ES, Wennberg JE, Stukel TA, Sharp SM. Hospital readmission rates for cohorts of Medicare beneficiaries in Boston and New Haven. N Engl Med 1994;331: 989-95.
Wennberg JE, Fisher ES, Skinner JS. Geography and the debate over Medicare reform. 2002. http://content.healthaffairs.org/cgi/content/full/hlthaff.w2.96v1/DC1 (accessed 4 Mar 2004).
Fisher ES, Wennberg DE, Stukel DA, Gottlieb D, Lucas FL, Pinder E. The implications of regional variations in Medicare spending: part 1, utilization of services and the quality of care. Ann Intern Med 2003;138: 273-87.
Fisher ES, Wennberg DE, Stukel DA, Gottlieb D, Lucas FL, Pinder E. The implications of regional variations in Medicare spending: part 2, health outcomes and satisfaction with care. Ann Intern Med 2003;138: 288-98.
Wennberg, JE. Unwarranted variations in healthcare delivery: implications for academic medical centres. BMJ 2002;325: 961-4.
America's best hospitals. US News and World Report 2001;131(3).
Iezzoni LI, Heeren T, Foley SM, Daley J, Hughes J, Coffman GA. Chronic conditions and risk of in-hospital death. Health Serv Res 1994;29: 435-60.
McCullagh P, Nelder JA. Generalized linear models. 2nd ed. New York: Chapman and Hall, 1989.
Wennberg J, Gittelsohn A. Small area variations in health care delivery: a population-based health information system can guide planning and regulatory decision-making. Science 1973;182: 1102-8.
Welch WP, Miller ME, Welch HG, Fisher ES, Wennberg JE. Geographic variation in expenditures for physicians' services in the United States. N Engl J Med 1993;328: 621-7.
Fisher ES, Wennberg JE, Stukel TA, Skinner JS, Sharp SM, Freeman JL, et al. Associations among hospital capacity, utilization, and mortality of U.S. Medicare beneficiaries, controlling for sociodemographic factors. Health Serv Res 2000;34: 1351-62.
Singer DE, Carr PL, Mulley AG, Thibault GE. Rationing intensive care—physician responses to a resource shortage. N Engl J Med 1983;309: 1155-60.
Strauss MJ, LoGerfo JP, Yeltatzie JA, Temkin N, Hudson LD. Rationing of intensive care unit services: an everyday occurrence. JAMA 1986;255: 1143-6.
Wasson JH, Gaudette C, Whaley F, Sauvigne A, Baribeau P, Welch HG. Telephone care as a substitute for routine clinic follow-up. JAMA 1992;267: 1788-93.
Weinberger M, Oddone EZ, Henderson WG, for the Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmission. Does increased access to primary care reduce hospital readmissions? N Engl J Med 1996;334: 1441-7.
Pritchard RS, Fisher ES, Teno JM, Sharp SM, Reding DJ, Knaus WA, et al. Influence of patient preferences and local health system characteristics on the place of death: study to understand prognoses and preferences for risks and outcomes of treatment. J Am Geriatr Soc 1998;46: 1242-50.
Schneiderman LJ, Gilmer T, Teetzel HD, Dugan DO, Blustein J, Cranford R, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial. JAMA 2003;290: 1166-72.(John E Wennberg, Peggy Y )
Correspondence to: J E Wennberg john.wennberg@Dartmouth.edu
Abstract
The frequency of use of hospitals, intensive care units, and physician visits among patients with chronic illness varies extensively across hospital regions in the United States, including regions served by well known academic medical centres. The variations are unrelated to population based measures of need but are closely associated with the per capita supply of hospital beds and physicians.1-4 The variations in frequency of use of these "supply sensitive" services during the last six months of life are particularly striking.1 These variations are of concern because they do not seem to reflect patients' preferences or rates of illness. Moreover, patients with chronic illnesses who live in regions with high rates of use do not seem to have better health outcomes.5-7 For these reasons, we have argued that the research agenda for academic medical centres should give high priority to comparative studies of their own patterns of practice with the goal of rationalising the management of chronically ill patients and answering questions about how many hospital beds and physicians are needed to provide optimal care.5 8 An important first step is to obtain population based performance measures specific to academic medical centres. In this paper, we document extensive variations in end of life care among cohorts of patients enrolled in Medicare who receive most of their inpatient care at well known academic medical centres in the United States.
Methods
Table 1 shows the characteristics of the study population. Of the 115 089 patients, 98 415 (85%) were chronically ill, many with two or more conditions. The intensity of care during the last six months of life and at the time of death varied substantially. The figure shows the standardised utilisation ratios and statistical measures of variation among the 77 hospital cohorts. Among the 77 hospital cohorts, the average number of days spent in hospital during the last six months of life was more than 27 days—almost a month—in the highest ranked cohort and fewer than 10 days in the lowest ranked cohort. Average ICU days varied by a factor of six, from 1.6 to 9.5 days per person; physician visits varied by a factor of four, from less than 18 to more than 76 visits per decedent. The propensity to use multiple physicians varied from less than 17% of patients seeing 10 or more physicians in the last six months of life to more than 58% of patients. The percentage of deaths occurring in hospital ranged from less than 16% to more than 55%; deaths associated with a stay in an intensive care unit varied from less than 9% to more than 36%. Enrolment in a hospice varied among the cohorts from less than 11% of decedents to more than 43%.
Table 1 Illness and demographic characteristics among patients assigned to 77 hospital cohorts. Values are numbers (percentages)
Distribution of rates and statistical measures of variation for end of life care among 77 cohorts assigned to hospitals with national reputations for high quality. ICU=intensive care unit
Table 2 examines the intensity of care during the last six months for cohorts loyal to major teaching hospitals located in metropolitan regions with two or more major teaching hospitals. They are ranked according to the (unweighted) average number of patient days per decedent. By this measure, the hospitals located in Manhattan provided the most care. Other regions with high hospital day rates included Los Angeles, Philadelphia, and Washington, DC. Patient cohorts loyal to the teaching hospitals in these regions also tended to have a higher frequency of physician visits, and a higher proportion saw 10 or more physicians. However, the use of intensive care units varied: the rates were high among the listed teaching hospital cohorts in Los Angeles, low in Washington, DC, and varied substantially according to specific hospital cohorts in Philadelphia and New York. Cohorts in Boston and St Louis exhibited considerable within area variation in hospital days and ICU days. By contrast, those in Minneapolis and San Francisco had low rates on all four measures of intensity of care in the last six months of life.
Table 2 Age, sex, race, and illness adjusted rates (95% confidence intervals) for hospital days, days in intensive care, and physician visits and percentage seeing 10 or more physicians during last six months of life among patient cohorts loyal to selected academic medical centres by region of location
The observed variation could have been generated by substitution between hospital use, physician visits, and hospice care. Enrolment in a hospice was inversely correlated with hospital days in the last six months of life (r = - 0.41; P < 0.0002), the chance of dying in a hospital (r = - 0.51; P < 0.0001), and the percentage of deaths occurring in association with a stay in the intensive care unit (r = - 0.28; P = 0.012). However, the percentage enrolled in a hospice was not correlated significantly (P > 0.05) with fewer physician visits, seeing 10 or more physicians, or ICU days in the last six months of life. We found a strong positive correlation between the number of days spent in hospital and the number of physician visits within the last six months of life (r = 0.77; P < 0.0001).
Discussion
Wennberg JE, Cooper MM, eds. The quality of medical care in the United States: a report on the Medicare program. The Dartmouth atlas of health care 1999. Chicago, IL: American Hospital Association Press, 1999.
Wennberg JE, Freeman JL, Culp WJ. Are hospital services rationed in New Haven or over-utilized in Boston? Lancet 1987;i: 1185-8.
Wennberg JE, Freeman JL, Shelton RM, Bubolz TA. Hospital use and mortality among Medicare beneficiaries in Boston and New Haven. N Engl J Med 1989;321: 1168-73.
Fisher ES, Wennberg JE, Stukel TA, Sharp SM. Hospital readmission rates for cohorts of Medicare beneficiaries in Boston and New Haven. N Engl Med 1994;331: 989-95.
Wennberg JE, Fisher ES, Skinner JS. Geography and the debate over Medicare reform. 2002. http://content.healthaffairs.org/cgi/content/full/hlthaff.w2.96v1/DC1 (accessed 4 Mar 2004).
Fisher ES, Wennberg DE, Stukel DA, Gottlieb D, Lucas FL, Pinder E. The implications of regional variations in Medicare spending: part 1, utilization of services and the quality of care. Ann Intern Med 2003;138: 273-87.
Fisher ES, Wennberg DE, Stukel DA, Gottlieb D, Lucas FL, Pinder E. The implications of regional variations in Medicare spending: part 2, health outcomes and satisfaction with care. Ann Intern Med 2003;138: 288-98.
Wennberg, JE. Unwarranted variations in healthcare delivery: implications for academic medical centres. BMJ 2002;325: 961-4.
America's best hospitals. US News and World Report 2001;131(3).
Iezzoni LI, Heeren T, Foley SM, Daley J, Hughes J, Coffman GA. Chronic conditions and risk of in-hospital death. Health Serv Res 1994;29: 435-60.
McCullagh P, Nelder JA. Generalized linear models. 2nd ed. New York: Chapman and Hall, 1989.
Wennberg J, Gittelsohn A. Small area variations in health care delivery: a population-based health information system can guide planning and regulatory decision-making. Science 1973;182: 1102-8.
Welch WP, Miller ME, Welch HG, Fisher ES, Wennberg JE. Geographic variation in expenditures for physicians' services in the United States. N Engl J Med 1993;328: 621-7.
Fisher ES, Wennberg JE, Stukel TA, Skinner JS, Sharp SM, Freeman JL, et al. Associations among hospital capacity, utilization, and mortality of U.S. Medicare beneficiaries, controlling for sociodemographic factors. Health Serv Res 2000;34: 1351-62.
Singer DE, Carr PL, Mulley AG, Thibault GE. Rationing intensive care—physician responses to a resource shortage. N Engl J Med 1983;309: 1155-60.
Strauss MJ, LoGerfo JP, Yeltatzie JA, Temkin N, Hudson LD. Rationing of intensive care unit services: an everyday occurrence. JAMA 1986;255: 1143-6.
Wasson JH, Gaudette C, Whaley F, Sauvigne A, Baribeau P, Welch HG. Telephone care as a substitute for routine clinic follow-up. JAMA 1992;267: 1788-93.
Weinberger M, Oddone EZ, Henderson WG, for the Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmission. Does increased access to primary care reduce hospital readmissions? N Engl J Med 1996;334: 1441-7.
Pritchard RS, Fisher ES, Teno JM, Sharp SM, Reding DJ, Knaus WA, et al. Influence of patient preferences and local health system characteristics on the place of death: study to understand prognoses and preferences for risks and outcomes of treatment. J Am Geriatr Soc 1998;46: 1242-50.
Schneiderman LJ, Gilmer T, Teetzel HD, Dugan DO, Blustein J, Cranford R, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial. JAMA 2003;290: 1166-72.(John E Wennberg, Peggy Y )