Academic medical centers like Johns Hopkins pride themselves on practicing medicine at the highest level. We assume that our results are likely to be superior, and further that there is probably less variability in outcomes among our peer academic institutions compared to community-based hospitals.
A recent research study by John Wennberg and his colleagues at Dartmouth Medical Center* cast some doubt on this assertion. Wennberg has established himself as the foremost figure on understanding the variability of care and costs in Medicare patients, and this study provides some interesting food for thought.
Wennberg looks at what he calls supply-sensitive care among 77 academic medical centers, most of them coming in high on the U.S. News & World Report ranking in particular specialties. He looked at patients with severe chronic illness who ultimately died and analyzed their care during the last six months of life.
Supply-sensitive care reflects care whose frequency is often determined by the level of supply. “Roemer’s Law” described such a phenomenon, wherein rates of hospitalization per thousand population correlated highly with the supply of staffed hospital beds. Similarly, a high number of neurosurgeons correlates directly with utilization of neurosurgical procedures, etc.
Wennberg’s group analyzed the number of days of hospitalization, number of ICU visits, number of physicians involved in the care of an individual patient and many other factors—all during the last six months of life in patients with such illnesses as congestive heart failure, chronic lung disease and cancer.
What his group found was that there was a large variability in these data, both on a regional basis but also within a region. For example, the number of hospital days during the last six months of life varied from 9.4 to 27.1. New York University Medical Center was at the high end, while its neighbor, Presbyterian Hospital, was 21.6 days. However, Stanford was 10.1; UCSF, 11.1; and UCLA, 16.1. Cedars-Sinai, a short cab ride from UCLA, was 21.3. Similar variability was found for ICU utilization, from 1.6 days to 9.5. UCLA had 9.5; UCSF, 2.6; NY Presbyterian, 4.5, and NYU, 6.7. Physician visits also varied, from 76.2 per patient for NYU Medical Center, to 27.2 for UCSF, and 22.6 for Stanford, for example.
So, how did we do? The data per patient for Hopkins are as follows: 16.1 hospital days, 3.2 ICU days and 28.1 physician visits. We certainly performed better than many of our peers, especially those on the East Coast, but still a long way from best in class by Wennberg’s measures. These data indicate that continued emphasis on effective control of utilization of expensive resources could have a significant improvement in the costs of caring for Medicare patients with serious illness.
* Wennberg et al:: Use of hospitals, physician visits and hospice care during last six months of life among cohorts loyal to highly respected hospitals in the United States. BMJ March 2004;328:607.
