Consumer Reports provides comparison of aggressive vs. conservative hospital care

The "more is better" approach to American health care has been challenged consistently over the last 15 years by research compiled by two Dartmouth Medical School physicians. As reported in previous issues of HealthFacts, these researchers have studied the care given to Medicare patients in the last two years of life and shown that more tests, more procedures, more specialist care, more days in the hospital do not lead to a longer life or a better quality of life.

Now Consumer Reports has put the Dartmouth findings in a consumer-friendly format that will help Americans determine whether a hospital in their part of the country is likely to deliver aggressive or conservative care. Nearly 3,000 hospitals across the U.S. are included in the new format, which will be available in the July 2008 issue of Consumer Reports and is freely accessible at the magazine's Web site. It relies on data from the Medicare claims records of over 4.7 million elderly people treated from 2001 through 2005 for severe illnesses like cancer, congestive heart failure, lung diseases, dementia and coronary heart disease.

The brains behind this research are John E Wennberg, MD, and Elliott S. Fisher, MD, at the Dartmouth Medical School, who have regularly published findings in medical journals as part of a 30-year study of U.S. health care. Entitled the Dartmouth Atlas of Health Care 2008, this research project has also made its findings freely available at its own Web site (www.dartmouthatlas.org).

Contrary to what many Americans believe, aggressive care and consulting many specialists do not improve outcomes or lead to more patient satisfaction. In fact, altogether they slightly increase mortality. The Dartmouth researchers demonstrated years ago that more care often results in more procedures that are painful and unnecessary; more days in the hospital raises the chances of suffering a medication error or getting a fatal hospital-borne infection; and more specialist care leads to uncoordinated care. (Get a good primary care doctor is one of the take-home messages of the Dartmouth researchers.)

At a time when hospitals typically advertise their new high-tech equipment and friendly staff members, Consumer Reports provides an easy way for the public to see just how aggressive their care will be compared to other hospitals in their cities. (Next, we need to know the infection rate of all U.S. hospitals.) It raises a larger question for everyone to consider: Since overly aggressive care is not limited to the elderly, how can people of any age protect themselves when they become hospital patients?

Things aren't likely to change until consumers make their wishes known and raise questions. Consumer Reports provides many excellent suggestions: Is this treatment likely to extend my life, and if so, for how long? How do its side effects and risks compare with the symptoms and risks of my disease itself? What will happen if I do not have the treatment? Will this test change the way you treat the disease? If not, what is the benefit of doing it? Is this test likely to lead to follow-up tests, biopsies, or other diagnostic procedures? How will this benefit my health?

The Consumer Reports Web site illustrates why New York University Langone Medical Center in Manhattan is #1 in the country in terms of delivering the most aggressive (and expensive) care. The Medicare cost per person in the last two years of life at this hospital was $105,067. This is compared with $44,090 at the country's #1 hospital in terms of the most conservative care--Scott & White Memorial Hospital in Temple, Texas. (Both are chosen from a subcategory of 93 U.S. hospitals called "integrated medical centers"--that is, hospitals affiliated with medical schools.)

The average patient treated at NYU hospital in the last two years of life spent 54 days in the hospital, 12 days in the ICU, had 34 primary-care visits and 97 specialist visits. The average patient at the Hospital in Temple, Texas spent 16 days in the hospital, four days in the ICU, had 23 primary-care visits and 18 specialist visits. Yet, as Consumer Reports notes, "The Centers for Medicare and Medicaid Services rates care at Scott & White to be at least as good as that at NYU."

The New York Times reported that the list of New York City hospitals at the Consumer Reports Web site shows a clear division in terms of aggressive care between the private and the public hospitals. As a group, the private hospitals were in the 94th percentile of aggressive care compared with the public hospitals in the 69th percentile. Although the latter is still above the national average, the difference cries out for explanation. The most obvious would be that poor people get inferior (i.e., less) care.

But an alternative explanation was provided to The New York Times by Dr. Eric Manheimer, who works for both the public and private systems as medical director at Bellevue (a public hospital) and faculty member of NYU medical school. "The care at public hospitals was less aggressive because most of their doctors--estimated at 75-85%--were salaried physicians with little financial incentive to order tests or other interventions. At private hospitals, supply can creates its own demand. There is often an abundance of beds and an endless list of specialists who can be called."