'Drastic' variations in care found at top academic medical centers

Patterns of care vary widely among 23 top U.S. academic medical centers, according to a report (PDF) from the Dartmouth Atlas Project. The report's authors suggest that these variations may be something medical students want to consider when choosing an institution for residency training.

Noting that all the institutions studied are affiliated with medical schools and "should be exemplars of evidence-based medicine," the report highlighted significant variations in intensity of end-of-life care, surgical procedure rates, patient-reported experience, patient safety and quality of care.

"These findings challenge the assumption that clinical science alone drives medical practice at these prestigious institutions and thus raise a serious issue for academic medicine," said Dr. David Goodman (PDF), co-principal investigator for the Dartmouth Atlas Project, and director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy & Clinical Practice, in a news release. "With such drastic variations from one institution to the next, they clearly cannot all be right. Academic medicine needs to address this gap in clinical science."

The report used 2010 Medicare data as well as Medicare data from 2008 to 2010 for surgical procedure measures, and the HHS Hospital Compare website for patient experience, patient safety and pneumonia-care quality comparisons.

Among the widest differences in care: Johns Hopkins Hospital, Baltimore, enrolled 49.4% of its chronically ill patients in a hospice program, whereas Mount Sinai Medical Center in New York enrolled 23.1%, and 66.6% of chronically ill patients at New York University Langone Medical Center saw 10 or more physicians in their last six months of life, compared with 42.5% who did the same at Scott & White Memorial Hospital in Temple, Texas.

Regionally, the study found that patients were more than twice as likely to get knee-replacement surgery in Salt Lake City, where the rate was 11.9 per 1,000 hospital discharges, than in Manhattan, where the rate was 4.5 per 1,000 discharges. Also, in Salt Lake City, the rate for radical prostatectomy was 2.5 per 1,000 discharges between 2008 and 2010, compared to 0.8 in San Francisco.

"We think it is really important information," Goodman said during a telephone news conference. "Those differences are invisible on the ground."

The report was co-authored by Dr. Anita Arora, a recent graduate of Dartmouth's Geisel School of Medicine, and Alicia True, a member of Geisel's class of 2015. Under the premise that the practice style and culture under which residents train will remain with them throughout their careers, the authors said medical students should use the information in the report to chart career choices.

"It shines a light on hospital characteristics that are often invisible but are part of the hidden training curriculum that can affect a lifetime of practice," the authors wrote. "These include how aggressively physicians at each hospital treat chronically ill patients at the end of life and the frequency with which patients undergo surgery when other treatment options are available."