More intensive care may not be better

WASHINGTON — More intensive medical care -- even at some of the most reputable hospitals in the nation -- does not necessarily translate into longer life or better health and may in fact leave patients worse off, according to research released Thursday.

Elderly patients with chronic illnesses who stay in the intensive care unit longer, receive more diagnostic tests or are treated by numerous specialists do not fare better than those who receive less intensive care, two studies conducted by Dartmouth Medical School found.

“We know hospitals are dangerous places,” said Elliott Fisher, one of the lead authors and co-director of the Veterans Affairs Outcomes Group, based in Vermont. “Higher intensity patterns of practice are associated with no better quality, and if anything, worse quality.”

Among older patients who were treated for a heart attack or colorectal cancer, there actually “was a small but statistically significant increase in the risk of death as intensity increased,” he found.

“It is clear that quality is inversely correlated with the intensity of care and that the better hospitals are using fewer resources and providing fewer hospitalizations and physician visits,” said coauthor John Wennberg, director of Dartmouth’s Center for Evaluative Clinical Sciences.

The studies, published in the journal Health Affairs, lend support to a growing movement in health policy circles toward “evidence-based medicine” in which doctors adhere to scientifically proven treatments and providers are paid for results rather than procedures.

For three decades, researchers at Dartmouth have tracked wide geographic variations in treatment patterns across the United States, focusing primarily on the underuse of types of care proven to be effective. More recently, the team shifted its attention to potential overuse of care. The reports published Thursday are the first to analyze treatment patterns at specific hospitals.

In the first report, Wennberg examined the Medicare records of 90,600 patients during their last six months of life in 77 well-regarded teaching hospitals. He compared frequency of doctor visits and hospitalizations and time in the intensive care unit for people with solid-tumor cancers, congestive heart failure and chronic lung disease.

He found dramatic variations in the amount of care given to patients with the same maladies. Patients at New York’s Mount Sinai Medical Center, for instance, spent almost twice as many days in the hospital as those in the Mayo Clinic’s St. Mary’s Hospital in Rochester, Minn.

The number of terminally ill patients who died in the hospital, rather than at home or in a hospice, ranged from 32% to 52%, despite surveys that indicate most Americans prefer not to die in a hospital.

“If you can get the same benefits for patients with lower intensity use, then you have a more efficient system in which to provide that care,” said Ralph Horwitz, dean of Case Western Reserve University School of Medicine in Cleveland. He said the studies were valuable because for too long “we have substituted volume for a measure of quality.”

Fisher’s analysis tracked mortality rates for Medicare patients in 300 hospitals for heart attacks, colorectal cancer or hip fractures.

After devising five categories based on “intensity” of care, he found that “high-intensity” institutions spent vastly more money -- on X-rays, specialist visits, in-patient care and follow-up -- than the “low-intensity” hospitals. But the high-end hospitals are “not doing a better job on quality,” he said.

The Health Affairs issue was underwritten by the WellPoint Foundation, a charitable arm of the California-based health insurer.