Study Traces Regional Disparity In Medical Care From Surgery To Medicare Stays, There Is Room For Improvement

The dying in St. Petersburg, Fla., can expect to spend almost five days longer in intensive care than old folks in Sun City, Ariz., says a study that concludes where Americans live helps determine how they spend their last days.

The Dartmouth Atlas of Health Care also found large geographic disparities in the number of days Medicare patients spent in the hospital during the last six months of life - from a low of 4.4 days in Ogden, Utah, to a high of 22.9 days in Newark, N.J.

Which rate is better? The atlas, compiled by renowned Dartmouth Medical School epidemiologist Dr. John Wennberg, cannot say. But it does conclude that the availability of hospital beds plays a big role.

“The issue of what care is right is a fundamental question,” said Dr. Jonathan Lord of the American Hospital Association, which published the 300-page study. “Geography is destiny. … Where you live basically determines how you’re going to die.”

Wennberg, who first uncovered regional variations in medicine in the 1980s, mapped the distribution of health care resources in 1994-95 - the latest data available - and how people in 306 hospital “referral regions” used them.

The study, released Wednesday, confirms earlier surgical disparities - that, for example, patients in some states get heart bypass surgery or mastectomies for breast cancer more often than less-invasive alternatives.

Numerous other surveys have documented the elderly saying they don’t want to die in hospitals or intensive-care units. But Wennberg discovered stark differences in how communities care for the dying:

Chances that a Medicare patient will be treated in intensive care during the last six months of life range from less than 9 percent in Sun City to more than 47 percent in Miami, St. Petersburg and Munster, Ind.

The actual time spent in ICU ranged from half a day in Sun City and a day in Portland and Salt Lake City to almost 5 days in St. Petersburg, Munster and Miami.

Dying Medicare patients were hospitalized longest in Newark, 22.9 days, and New York City’s Manhattan, 22 days. The longest hospital stays were in the Northeast and Deep South, while the West had the shortest, including 4.4 days in Ogden, Utah, and 5.3 days in Salt Lake City.

The percent of deaths among Medicare patients that occurred in a hospital ranged from 22 percent in Portland, to 51 percent in Newark.

What’s happening? Compare Arizona and Florida. They have similar death rates, despite the hospitalization disparities.

That suggests Sun City’s approach, “even though this is considered less aggressive, it is appropriate therapy,” said Dr. Walter Nieri of the St. Joseph’s Geriatric Fellowship Program. “In order to die, do I need to be in a hospital with a catheter, the IV on and fully tubed? No.”

The findings “strongly suggest there’s some room for improvement,” said Dr. Beth Virnig of the University of Miami and Miami Veterans Affairs. But “it’s too easy to say ICU care in the elderly is bad” because doctors just don’t know for sure who they can save.

But patients play a role, too.

Sun City runs an aggressive community education program that teaches about common diseases and patients’ rights to accept or reject treatment.

Many doctors believe that “if patients realized what (care) they were getting and what their chances of success were, they would never agree to it,” Miami’s Virnig agreed. “Take CPR in the elderly: No matter what you see on ‘ER,’ it just doesn’t work.”

So what city is right? “The truth is probably in the middle,” she said.