When conservative care is plenty
The other day, I looked up my hometown hospital, Mercy Medical Center in Mason City, Iowa, on our new hospital comparison tool and was startled to see that it ranks in the 1st percentile in conservative care. In other words, 99 percent of hospitals deliver more aggressive medical care to people during the last two years of life than does the hospital across the street from where I grew up.
It's also the hospital that cared for my mother in the last 12 years of her life, a period in which she struggled with two types of cancer, a broken neck that required surgery and chronic lung disease that required vigilant management to keep from flaring into pneumonia. Her various physicians and home health caregivers paid close attention to her needs. They managed to keep her at home and reasonably active for a long time, until she developed inoperable esophageal cancer. Death came peacefully in 2002, in a state-of-the-art inpatient hospice facility.
To many of us, aggressive care seems better. So how, I wondered, could we have been satisfied with a hospital (and its doctors), that practice the most conservative care in the land? Or, for that matter, failed to notice that the care was conservative in the first place? A study in the May 28, 2008 issue of the Journal of the American Medical Association helps answer my questions.
A research team from not-for-profit Foundation for Informed Medical Decision Making—affiliated with the pioneering Dartmouth Atlas of Health Care, the data source for our hospital comparison tool—ran the JAMA study. The team, lead by Floyd J. Fowler Jr., Ph.D., asked a national sample of 2,515 Medicare patients to assess the quality of their health care. Then they looked to see whether patients in higher-cost regions thought they got better care than people treated in more low-spending areas.
They didn’t. One-third of patients in the most frugal regions, where Medicare spent an average of $5,209 per patient in 2003, rated their care as "better than average." So did one-third of patients in the highest-spending regions, which blew through $8,522 per patient in the same timeframe. The two groups were also, on average, just as happy with the amount of time their doctors spent with them.
Surprisingly, the people in the high-spending regions who received the most care felt they were getting too little care at times. For instance, 40 percent of the patients in the lowest-spending regions said they'd had a cardiac test (an angiogram, electrocardiogram, or stress test) in the previous year, compared with 64 percent in the highest-spending regions. Yet in both groups the same percentage complained that they had "too few" tests for heart disease. And patients in the high-spending regions were more likely to complain of difficulty getting appointments with specialists, even though they went to the doctor more often and saw more doctors.
The authors of the study theorize that patients' perception of the quality of their care may have as much to do with expectations as with outcomes. Patients in regions that practice aggressive care come to expect it, while people in places like Mason City are accustomed to more conservative care. When their expectations are met, they're content.
This is encouraging news for anyone interested in how we can afford to extend health care coverage to the 47 million Americans who currently don't have it. If the most aggressive (and therefore expensive) care doesn't make people happier, or healthier, or even live longer, then ways to make more places look like Mason City should be considered. As I can personally attest, you’d probably never notice the difference.
—Nancy Metcalf, senior project editor
Posted by: Harold Gray | Jun 13, 2008 9:08:50 PM
TOOK WIFE TO HOS'P ER ON FRI. EVE BECAUSE SHE FELL OUT OF BED. WAS XRAYED AND TOLD OK. BY WED. SHE SUFFERED SO MUCH PAIN DR. SENT HER BACK TO ER AND HAD MRI DONE. FOUND COMPRESSION FRACTURE AT T6. ADMITTED TO HOS'P. FOR PAIN CONTROL. FOLLOWING SUNDAY WHEN I VISITED HER THE SOCIAL WORKER INFORMED ME SHE WOULD BE RELEASED THE NEXT DAY AND WOULD GO TO REHAB CENTER FOR A COUPLE OF WEEKS. THAT EVENING I RECEIVED A CALL FROM THE HOS'P. TELLING ME SHE HAD FALLEN AND XRAYS WERE BEING DONE. WENT TO HOS'P. AND THEY INFORMED ME SHE HAD A SPIRAL FRACTURE TO THE RT. FEMUR AND WOULD NEED SURGERY QUICKLY. PUT ROD IN FEMUR AND SHE SPENT ONE WEEK IN ICU THEN VACK TO HER FLOOR AND THE NEXT DAY THEY TOLD ME THEY HAD TO RELEASE HER TO A REHAB CENTER WHERE SHE IS STILL AT AND I DON'T KNOW IF SHE WILL EVER BE BACK HOME.THE HOSPITAAL IS NOT ACCEPTING ANY RESPONSIBILITY FOR THIS. SHE IS 82 AND MEDICARE IS HAVING TO COVER THE EXPENSE OF THEIR ERROR. IF YOU ARE INTERESTED IN THIS CASE CONTACT ME AND I WILL FURNISH YOU WITH THE PARTICULARS.