TUESDAY, March 15 (HealthDay News) -- The likelihood of Medicare
patients being diagnosed with a chronic disease may depend on where
they live, a disparity that makes it more difficult to assess the
quality of care patients receive, a new study finds.
Certain groups of Medicare patients in regions with the most
diagnoses also had a lower case-fatality rate for chronic
conditions such as coronary artery disease and kidney failure, but
the reasons for that are unclear, the researchers reported.
It would stand to reason that whether a person is diagnosed with
a chronic disease has to do with how ill they are, the researchers
But instead, the findings suggest that chronic disease diagnosis
is influenced by the "intensity of health care" in a particular
region, which includes how many doctors and specialists are
operating in a particular region, access to those doctors and the
likelihood of doctors to send you to a specialist or to order lab
and imaging tests.
"The study suggests disease diagnosis is not only a property of the patient, but associated with the intensity with which health care is delivered in a region," said senior study author Dr. John Wennberg, a professor emeritus and founder of the Dartmouth Institute. "For example, if in certain regions people see lots of doctors, have lots of visits to doctors and lots of lab tests, that could be because there is a perfect relationship between illness and the amount of care that's delivered. But it could be that the more doctors you see, the more diagnoses you get."
The study, conducted by Dr. H. Gilbert Welch of the Department
of Veterans Affairs Medical Center, White River Junction, Vt., and
colleagues, appears in the March 16 issue of the
Journal of the American Medical Association. It was funded in part by the National Institute on Aging.
Researchers analyzed records on nearly 5.2 million Americans
aged 65 and up who received fee-for-service Medicare benefits in
2007. In particular, they examined data on diagnoses of nine
serious chronic conditions: cancer, chronic obstructive pulmonary
disease, coronary artery disease, congestive heart failure,
peripheral artery disease, severe liver disease, diabetes with
end-organ disease, chronic renal failure and dementia.
The mean number of chronic health conditions diagnosed was 8.7
for every 10 people. But that varied significantly depending on
which of the 306 U.S. regions patients sought care.
On the low end, patients in the Grand Junction, Colo., and Idaho
Falls, Idaho, were diagnosed with 5.8 chronic illnesses for every
10 people, compared to more than 12 illnesses for every 10 people
in Miami and McAllen, Texas.
Not surprisingly, the more chronic conditions a person had, the
more likely they were to die. The fatality rate among people with
no chronic health conditions was 16 per 1,000 annually; 45 per
1,000 for those with one condition; 93 per 1,000 for those with two
Yet paradoxically, among subgroups of Medicare patients in
regions where patients tended to receive more diagnoses, the risk
of death from a chronic condition falls.
Patients were divided in quintiles (or fifths) based on the
frequency of diagnoses in that region.
Among patients with one chronic condition, 51 per 1,000 of those
in the lowest quintile for diagnoses died, compared to only 38 per
1,000 in the highest quintile. For patients diagnosed with three
conditions, 168 died in the lowest quintile compared to 137 per
1,000 in regions where chronic conditions were more readily
That could be because they receive far better care, Wennberg
said. But more likely, the real reason is because in "high
intensity" health-care regions, patients are more likely to be
diagnosed with a chronic illness even if it's not particular
serious or they're not actually ill.
The data show that as the number of diagnoses rise, so do the
number of doctor visits, different doctors seen, imaging tests and
lab tests done.
"Doctors make diagnoses," Wennberg said. "If you go to lots of doctors and doctors, they are going to make more diagnoses."
This complicates efforts to measure the quality and
effectiveness of care, said Dr. Ashish Jha, an associate professor
of health policy at the Harvard School of Public Health.
In an effort to improve health care, there's a growing movement
to grade doctors and hospitals on performance, and to attach pay to
how well doctors perform.
To make things fair, grading systems usually account for how
sick patients are to avoid penalizing doctors who are taking care
of a sicker group of people.
But research such as this study shows such methods may be
flawed, because those who appear to have more chronic illnesses may
not actually be any sicker than those with fewer chronic illnesses,
and vice versa, he said.
Put simply: a patient diagnosed with heart disease and diabetes
would be sicker than a patient with only one condition, but whether
they are diagnosed with both may be more related to where they live
and how many doctors they see.
Or, perhaps a patient gets an X-ray and is surprised to learn
she has mild lung disease. If she were in another region were lower
intensity healthcare, she might never get that X-ray and she'd feel
fine and never learn she had lung disease.
But if those doctors in the high-intensity region "get credit"
for having a sicker patient due to the chronic disease diagnosis,
it may look like they're performing better when they're actually
"This is a really important study and a really important finding," Jha said. "If you are a doctor who is very good, but you don't order lots and lots of tests, it might look like your patients are not that sick and therefore your outcomes might look worse. Obviously, the last thing we want to do is penalize doctors for being cautious and prudent and not overspending on tests and imaging studies or being overly aggressive."
One potential solution is the increasing use of electronic
health records, which will enable data from patients charts to be
more easily and readily analyzed when doing risk adjustment, Jha
said. Currently, with so many physicians still using paper records,
risk adjustment is done using insurance claims data, which is
incomplete and doesn't get into great detail about how sick
patients actually are.
"We want to be able to differentiate between the one who is really sick with lung disease vs. someone who has something minor but is otherwise OK," Jha said. "You can't get it from claims or billing data, but you can get that from clinical records, and the broader use of electronic health records will help that."
For more on chronic illness care, go to the
Agency for Healthcare Research.
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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