With medicine, less may be better researchers say

Regions of the United States where more health care is delivered don't provide better care than regions with more conservative practice patterns, according to two new studies by researchers at Dartmouth Medical School and the Veteran Affairs Medical Center in White River Junction, VT.

The studies, published in the Feb. 18 issue of Annals of Internal Medicine, examined how regional differences in the amount of care received by Medicare patients affected quality of and access to care, as well as outcomes and patient satisfaction. Researchers found that performing more medical services did not improve any of these health care measures. In fact, on some measures, such as access to preventive care, high-intensity regions actually fared worse.

While previous research has shown that the amount of money spent on health care and the number of medical services performed varies widely between regions, the studies are the first to comprehensively assess the impact of this variation on health care outcomes.

"People assume that more medical care means better medical care. What this study shows us is that a large fraction -- perhaps a third -- of medical care is devoted to services that do not necessarily improve health outcomes or the quality of care," said lead researcher Dr. Elliott Fisher, Co-Director of the Outcomes Group at the Veterans Affairs Medical Center, White River Junction, VT, and a professor of medicine at Dartmouth Medical School. "It suggests that care in the U.S. could be just as good or better and cost a lot less -- perhaps as much as 30% less -- if all U.S. regions could safely adopt the more conservative practice patterns of lower-cost regions."

In regions with nearly identical health care needs, Dr. Fisher's team found that the overall quantity of services performed could vary by as much as 60%. More frequent physician visits, greater use of specialists and minor tests, and more in-patient stays were responsible for most of the difference. Despite receiving more care, patients in higher intensity regions did not have better chances of survival, nor did they express greater levels of satisfaction with their care than did people in more conservative regions. On some measures, such as quality of care and access to outpatient services and preventive care like flu shots and Pap tests, higher-intensity regions actually fared worse than conservative regions.

Fisher suggested the studies, which received grant support from the Robert Wood Johnson Foundation, the National Cancer Institute and the National Institute of Aging at the National Institutes of Health, have implications for consumers, as well as for policy makers.

"For patients, our findings underscore the importance of evidence-based and conservative practice," Fisher said. "Where major treatment choices are involved, patients should ask: What's known about the outcomes of this treatment compared to the best alternative? And where there is uncertainty, our findings suggest a more conservative approach to treatment may be just as safe -- and perhaps safer -- than a more aggressive approach.

"For policy makers, our research points to the importance of controlling the capacity of the health care system. Most of the regional differences we found are due to the greater numbers of medical specialists and hospital beds in higher intensity regions. We should also focus on rewarding health care systems for providing better care, not more or less care," he said. "We learned from the managed care backlash that patients fear rationing. We need to develop and put in place performance measures that demonstrate convincingly to patients the safety, quality and efficiency of their providers."

SOURCE:  "The Implications of Regional Variations in Medicare Spending. The Content, Quality, and Accessibility of Care," Annals of Internal Medicine, Feb. 18, 2003 .