Dartmouth Aggressiveness
and Surgical Outcomes
Jeffrey H. Silber, M.D., Ph.D.
Center for Outcomes Research
The Children’s Hospital of Philadelphia
and
The Leonard Davis Institute of Health
Economics
The University of Pennsylvania
AcademyHealth Chicago, 2009
Co-Authors
• Robert Kaestner, Ph.D. (Institute of Government
and Public Affairs, University of Illinois at Chicago)
• Yanli Wang (Center for Outcomes Research,
CHOP)
• Laura Bressler, B.A. (Center for Outcomes
Research, CHOP)
• Orit Even-Shoshan, B.S. (Center for Outcomes
Research, CHOP)
Introduction
• Elliott Fisher and investigators at Dartmouth
have contended that there is considerable waste
in our health care system
• Through examining care near the end of life, the
Dartmouth group has typed hospitals by the
amount of resources expended on patients who
ultimately died—suggesting in effect that this
futile, aggressive care was, by definition,
wasteful
Implications of the Dartmouth
Findings
• The findings are intoxicating, in exactly the same
manner that Wennberg’s work 25 years ago
struck a chord with health care economists,
health services researchers and policy makers—
Why was healthcare spending in Boston so much
more per capita than in New Haven?
• The general public is now being told that more
aggressive care adds nothing to quality—In
effect, there is no trade-off. We can save money
and all be better off by reducing aggressiveness.
“In a 2003 study, another Dartmouth team, led
by the internist Elliott Fisher, examined the treatment
received by a million elderly Americans diagnosed
with colon or rectal cancer, a hip fracture, or a heart
attack. They found that patients in higher-spending
regions received sixty per cent more care than
elsewhere. They got more frequent tests and
procedures, more visits with specialists, and more
frequent admission to hospitals. Yet they did no
better than other patients, whether this was
measured in terms of survival, their ability to
function, or satisfaction with the care they
received. If anything, they seemed to do worse.
That’s because nothing in medicine is
without risks. Complications can arise from
hospital stays, medications, procedures, and
tests, and when these things are of marginal value
the harm can be greater than the benefits.”
Implication from Dr. Gawande
• Aggressiveness is bad for patients
• Survival rates are no better
• Complication rates may be worse
Consumer Reports Health.org on Dartmouth
Aggressiveness: July 2008
“Too much treatment?
Aggressive medical care can lead to more pain with no gain
For many consumers, good health care means seeing as many specialists as
possible. It may also mean undergoing rounds of tests and, if a serious illness is
diagnosed, prolonged hospital stays and extensive treatment.
Though the idea that more health care is better seems to make sense, recent
research has shown that none of the above necessarily helps you live better or longer.
In fact, too much medical care might shorten your life.
Those findings grew out of the 2008 Dartmouth Atlas of Health Care study and almost
three decades of research by John E. Wennberg, M.D., and colleagues at Dartmouth
Medical School. Their study of 4,732,448 Medicare patients at thousands of hospitals
in the U.S. from 2001 through 2005 found significant variations in the way that people
with serious illnesses such as heart failure and cancer were treated during the last two
years of their lives. Some regions used two or three times the medical and financial
resources than others.”
“Other Dartmouth research has found that
patients with serious conditions who are
treated in regions that provide the most
aggressive medical care—more tests and
procedures, more specialists, and more
days in the hospital—don't live longer or
enjoy a better quality of life than those who
receive more conservative treatment.
The Dartmouth study by John E.
Wennberg, M.D.,… and Elliott S. Fisher,
M.D., found that extra care didn't lead to
better results.
Consumer
Reports
Health.org
July 2008
Patients treated most aggressively are at
increased risk of infections and medical
errors that come from uncoordinated care,
such as doctors prescribing drugs that
duplicate or interact with other drugs. They
also tend to receive poorer care, spend a
lot more money for co-payments, and are
the least satisfied with their health care, the
Dartmouth researchers found.”
Implications from Consumers
Reports Health.org
• Aggressiveness increases complications
• Aggressiveness increases mortality
Implications
• If Dartmouth Aggressiveness increases
complication and mortality rates, then
aggressiveness is undesirable and VERY
wasteful (as it is more expensive to be
aggressive).
• Hence, there is a potential PAINLESS
solution to our society’s health care cost
crisis! Stop being aggressive! Save lives
and money!
Aggressiveness and Surgical
Outcomes
• We ask: Do hospitals with more aggressive
Dartmouth styles display different surgical
complication and mortality rates than those who
are less aggressive?
• Population: All Medicare patients in the US
(between 2002-2005) undergoing
– General Surgery (N=1,673,917)
– Orthopedic Surgery (N=2,507,312)
– Vascular Surgery (N=376,986)
Define Aggressiveness
• The hospital specific Dartmouth Atlas
inpatient spending figure—an aggregate
measure of aggressiveness.
• The measure is hospital specific—this is
not the observed hospital spending on an
individual patient at an individual hospital
• We will also report on Dartmouth total
hospital days and ICU days
Dartmouth Atlas “Aggressiveness”
or the “End of Life” Measures
• The Dartmouth Atlas of Health Care 2008 constructed
measures of a hospital’s intensity of resource use during
the last two years of life for all decedents with nine
chronic illnesses:
–
–
–
–
–
–
–
–
–
Malignant Cancer/Leukemia
Congestive Heart Failure
Chronic Pulmonary Disease
Dementia
Diabetes with End Organ Damage
Peripheral Vascular Disease
Chronic Renal Failure
Severe Chronic Liver Disease
Coronary Artery Disease
• The EOL measures were calculated for the period 2001
to 2005.
QUESTIONS
• Is increased Dartmouth Aggressiveness
associated with more complications?
• Is increased Dartmouth Aggressiveness
associated with worse outcomes of death
and failure-to-rescue?
The Model
• We utilized adjustment models that were similar
to those we previously published (see Volpp
2007a,b JAMA, Silber et al. Medical Care 2007,
Archives of Surgery 2009).
• The combined model included 30 covariates, 34
interaction terms and 183 procedures. Individual
models for general surgery, orthopedic surgery
and vascular surgery were also constructed.
Outcome Measures
• Death (30 days from admission)
• Complications: one of 42 events that
reflect events occurring after
hospitalization and surgery
• Failure-to-Rescue (the probability of death
given a complication)
Results
COMPLICATIONS
Dartmouth Aggressiveness (in $10,000 units) and its
Association with Complications in Combined Surgery
Odds
Ratio
95% CI
P-Value
Number of
Patients
Rate
C-Statistic
Patient
Characteristics
1.01
(1.00-1.02)
p=0.058
4,469,047
43.52%
0.785
Pt and Hosp
Characteristics
1.01
(1.00-1.03)
p=0.051
4,465,736
43.52%
0.785
Pt, Hosp Char
& Region
1.01
(1.00-1.03)
p=0.091
4,465,736
43.52%
0.785
Pt, Hosp Char
& Hospital
(RE Model)
1.01
(1.00-1.03)
p=0.066
4,465,736
43.52%
0.794
Complications
Hospital Adjustments include RB ratio, NTB ratio, N-Mix ratio, Technology and Size
Regions are the ten Medicare Regions. RE Model refers to Random Effects model using SAS
GLIMMIX
Dartmouth Aggressiveness (in Hospital days) and its
Association with Complications in Combined Surgery
Odds
Ratio
95% CI
P-Value
Number of
Patients
Rate
C-Statistic
Patient
Characteristics
1.01
(1.01-1.01)
p=0.1452
4,558,215
43.47%
0.785
Pt and Hosp
Characteristics
1.01
(1.01-1.01)
p=0.2204
4,554,904
43.47%
0.785
Pt, Hosp Char
& Region
1.00
(1.00-1.00)
p=0.9481
4,554,904
43.47%
0.785
Pt, Hosp Char
& Hospital
(RE Model)
1.00
(1.00-1.01)
p=0.6450
4,554,904
43.47%
0.794
Complications
Hospital Adjustments include RB ratio, NTB ratio, N-Mix ratio, Technology and Size
Regions are the ten Medicare Regions. RE Model refers to Random Effects model using SAS
GLIMMIX
Dartmouth Aggressiveness (in ICU days) and its
Association with Complications in Combined Surgery
Odds
Ratio
95% CI
P-Value
Number of
Patients
Rate
C-Statistic
Patient
Characteristics
0.99
(0.99-1.00)
p=0.4851
4,542,478
43.47%
0.785
Pt and Hosp
Characteristics
1.00
(0.99-1.00)
p=0.6592
4,539,167
43.47%
0.785
Pt, Hosp Char
& Region
1.00
(0.99-1.00)
p=0.8007
4,539,167
43.47%
0.785
Pt, Hosp Char
& Hospital
(RE Model)
0.99
(0.99-1.00)
p=0.4409
4,539,167
43.47%
0.794
Complications
Hospital Adjustments include RB ratio, NTB ratio, N-Mix ratio, Technology and Size
Regions are the ten Medicare Regions. RE Model refers to Random Effects model using SAS
GLIMMIX
30-DAY MORTALITY
Dartmouth Aggressiveness (in $10,000 units) and its
Association with Mortality in Combined Surgery
Odds
Ratio
95% CI
P-Value
Number of
Patients
Rate
C-Statistic
Patient
Characteristics
0.93
(0.91-0.94)
p<0.0001
4,469,047
4.27%
0.865
Pt and Hosp
Characteristics
0.94
(0.92-0.95)
p<0.0001
4,465,736
4.27%
0.865
Pt, Hosp Char
& Region
0.93
(0.91-0.95)
p<0.0001
4,465,736
4.26%
0.865
Pt, Hosp Char
& Hospital
(RE Model)
0.94
(0.93-0.95)
p<0.0001
4,465,736
4.27%
0.866
Mortality
Hospital Adjustments include RB ratio, NTB ratio, N-Mix ratio, Technology and Size
Regions are the ten Medicare Regions. RE Model refers to Random Effects model using SAS
GLIMMIX
Dartmouth Aggressiveness (in Hospital days) and its
Association with Mortality in Combined Surgery
Odds
Ratio
95% CI
P-Value
Number of
Patients
Rate
C-Statistic
Patient
Characteristics
0.94
(0.94-0.95)
p<0.0001
4,558,215
4.25%
0.865
Pt and Hosp
Characteristics
0.95
(0.94-0.95)
p<0.0001
4,554,904
4.25%
0.865
Pt, Hosp Char
& Region
0.94
(0.93-0.94)
p<0.0001
4,554,904
4.25%
0.865
Pt, Hosp Char
& Hospital
(RE Model)
0.94
(0.94-0.95)
p<0.0001
4,554,904
Mortality
4.25%
0.866
Hospital Adjustments include RB ratio, NTB ratio, N-Mix ratio, Technology and Size
Regions are the ten Medicare Regions. RE Model refers to Random Effects model using SAS
GLIMMIX
Dartmouth Aggressiveness (in ICU days) and its
Association with Mortality in Combined Surgery
Odds
Ratio
95% CI
P-Value
Number of
Patients
Rate
C-Statistic
Patient
Characteristics
0.95
(0.95-0.95)
p<0.0001
4,542,478
4.25%
0.865
Pt and Hosp
Characteristics
0.96
(0.96-0.97)
p<0.0001
4,539,167
4.25%
0.865
Pt, Hosp Char
& Region
0.96
(0.96-0.97)
p<0.0001
4,539,167
4.25%
0.865
Pt, Hosp Char
& Hospital
(RE Model)
0.96
(0.95-0.96)
p<0.0001
4,539,167
4.25%
0.866
Mortality
Hospital Adjustments include RB ratio, NTB ratio, N-Mix ratio, Technology and Size
Regions are the ten Medicare Regions. RE Model refers to Random Effects model using SAS
GLIMMIX
FAILURE-TO-RESCUE
Dartmouth Aggressiveness (in $10,000 units) and its
Association with Failure-to-Rescue in Combined Surgery
Odds
Ratio
95% CI
P-Value
Number of
Patients
Rate
C-Statistic
Patient
Characteristics
0.92
(0.90-0.94)
p<0.0001
1,945,101
9.80%
0.789
Pt and Hosp
Characteristics
0.93
(0.91-0.95)
p<0.0001
1,943,638
9.80%
0.790
Pt, Hosp Char
& Region
0.92
(0.90-0.94)
p<0.0001
1,943,638
9.80%
0.789
Pt, Hosp Char
& Hospital
(RE Model)
0.93
(0.92-0.94)
p<0.0001
1,943,638
9.80%
0.795
FTR
Hospital Adjustments include RB ratio, NTB ratio, N-Mix ratio, Technology and Size
Regions are the ten Medicare Regions. RE Model refers to Random Effects model using SAS
GLIMMIX
Dartmouth Aggressiveness (in Hospital days) and its
Association with Failure-to-Rescue in Combined Surgery
Odds
Ratio
95% CI
P-Value
Number of
Patients
Rate
C-Statistic
Patient
Characteristics
0.93
(0.93-0.94)
p<0.0001
1,981,626
9.78%
0.789
Pt and Hosp
Characteristics
0.94
(0.94-0.95)
p<0.0001
1,980,163
9.78%
0.789
Pt, Hosp Char
& Region
0.93
(0.93-0.94)
p<0.0001
1,980,163
9.78%
0.789
Pt, Hosp Char
& Hospital
(RE Model)
0.94
(0.94-0.94)
p<0.0001
1,980,163
9.78%
0.795
FTR
Hospital Adjustments include RB ratio, NTB ratio, N-Mix ratio, Technology and Size
Regions are the ten Medicare Regions. RE Model refers to Random Effects model using SAS
GLIMMIX
Dartmouth Aggressiveness (in ICU days) and its
Association with Failure-to-Rescue in Combined Surgery
Odds
Ratio
95% CI
P-Value
Number of
Patients
Rate
C-Statistic
Patient
Characteristics
0.95
(0.94-0.95)
p<0.0001
1,974,837
9.78%
0.789
Pt and Hosp
Characteristics
0.96
(0.95-0.96)
p<0.0001
1,973,374
9.78%
0.789
Pt, Hosp Char
& Region
0.96
(0.95-0.96)
p<0.0001
1,973,374
9.78%
0.789
Pt, Hosp Char
& Hospital
(RE Model)
0.95
(0.95-0.96)
p<0.0001
1,973,374
9.78%
0.795
FTR
Hospital Adjustments include RB ratio, NTB ratio, N-Mix ratio, Technology and Size
Regions are the ten Medicare Regions. RE Model refers to Random Effects model using SAS
GLIMMIX
Complications
50
p=0.051
p=0.2204
p=0.6592
Complication Rate (%)
45
40
35
30
25th %ile
25
75th %ile
20
15
10
5
0
Dartmouth Inpatient
Spending
Hospital Days
ICU Days
Dartmouth Aggressiveness Measures (25th %ile vs. 75%ile)
Directly standardized results using patient and hospital characteristics
Mortality
6
Mortality Rate (%)
5
p<0.0001
p<0.0001
p<0.0001
4
25th %ile
3
75th %ile
2
1
0
Dartmouth Inpatient
Spending
Hospital Days
ICU Days
Dartmouth Aggressiveness Measures (25th %ile vs. 75th %ile)
Directly standardized results using patient and hospital characteristics
Failure-to-Rescue (FTR)
11
p<0.0001
p<0.0001
p<0.0001
10
9
FTR Rate (%)
8
7
6
25th %ile
5
75th %ile
4
3
2
1
0
Dartmouth Inpatient
Spending
Hospital Days
ICU Days
Dartmouth Aggressiveness Measures (25th %ile vs. 75th %ile)
Directly standardized results using patient and hospital characteristics
Implications Regarding Aggressiveness
• Unlike suggestions by the Dartmouth
group, Atul Gawandi and Consumer
Reports, aggressiveness:
– HAS ALMOST NO ASSOCIATION WITH
SURGICAL COMPLICATIONS
– IS ASSOCIATED WITH DECREASED
30-DAY MORTALITY AFTER SURGERY
– IS ASSOCIATED WITH DECREASED
FAILURE TO RESCUE
Implications regarding potential
health care restructuring
• Policy measures that tend to limit the
aggressive style of hospitals may have
negative effects on quality
• There appears to be valid reasons why
some hospitals provide aggressive care
• The public should understand that
reducing aggressiveness may save
money, but may have undesirable
consequences