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For elderly patients, risks associated with a newly diagnosed disease may be less than competing risks of death and disability from other causes. Treatment benefits should be viewed in the context of normal life expectancy and quality of life.

Medicare's home health care program, consisting primarily of home visits by nurses and health aides, was conceived as a means to facilitate hospital discharge. Because home health care is now one of the fastest-growing categories of Medicare expenditures, we analyzed Medicare claims data to determine current patterns of use.We used 1993 data from Medicare's National Claims History File to examine the temporal relation between home visits and hospital discharge, as well as the number of months Medicare enrollees received home health care. To determine whether home visits replaced hospital services, we calculated population-based utilization rates, adjusted for age and sex, for enrollees living in the 310 U.S. metropolitan statistical areas and determined whether the areas with higher rates of home health care also had lower admission rates or shorter lengths of stay. Finally, we compared the geographic variation in use of home health care with that of other Medicare services.Roughly 3 million Medicare enrollees received over 160 million home health care visits in 1993. Seventy-eight percent of the visits either occurred more than a month after hospital discharge (35 percent) or were not associated with any inpatient care during the previous six months (43%). Home health care often represented a long-term intervention: 61 percent of the visits were to enrollees who received home health care for six months or more. We could find no evidence that home health care was substituted for hospital care; the metropolitan statistical areas with higher rates of home health care did not have fewer hospital admissions or shorter lengths of stay. There was more geographic variation in the use of home health care than in the use of other major categories of Medicare services (e.g., hospital admissions and physicians' services). Five states (all in the South) had more than 9000 visits per 1000 enrollees, and 14 states had fewer than 3000 visits per 1000 enrollees.Home health care visits are used primarily to provide long-term care. There is no evidence that services provided at home replace hospital services, and the dramatic geographic variation in home visits suggests a lack of consensus about their appropriate use.

The national volume-performance standard recently implemented by Medicare does not account for geographic variation in expenditures for physicians' services. To study this variation, we examined expenditures for physicians' services in all metropolitan areas in the United States.We used Medicare claims data for 1989 to measure rates of service use for beneficiaries living in the 317 U.S. metropolitan statistical areas (MSAs). The variables investigated were rates of admission to the hospital, payments to physicians for inpatient care per admission and per beneficiary, payments to physicians for outpatient care per beneficiary, and overall payments to physicians per beneficiary. Expenditures were measured in terms of allowed charges as adjusted to reflect prevailing charges in each MSA. Rates of use were adjusted for age and sex, with the exception of the variable for payments to physicians for inpatient care per admission, which was adjusted for case mix.Expenditures for the delivery of physicians' services to Medicare beneficiaries varied markedly among MSAs, with those for the areas with the lowest and the highest rates differing at least twofold on each measure. The measures for specific areas varied in parallel: areas with high rates of admission tended to have high levels of payment to physicians for inpatient care per admission, and areas with high payments for inpatient services tended to have high payments for outpatient services. Expenditures were not related to the number of physicians per capita but were lower in MSAs with a high proportion of primary care practitioners. The variation persisted when the 25 largest MSAs were examined; for total payments to physicians per beneficiary, there was a twofold difference between the area with the lowest rate and that with the highest, San Francisco ($872) and Miami ($1,874). The states with the highest overall payments to physicians per beneficiary were Florida, Louisiana, and Michigan.The marked variation among metropolitan areas in payments to physicians underscores the lack of consensus among physicians about which services are required. Moreover, the practice style in a given community appears to be influenced not by the aggregate supply of physicians but rather by the mixture of primary care physicians and specialists.

Many have proposed blueprints for a new U.S. health care system, but few have focused on the process of designing a house we all can live in. Perhaps because we physicians are both providers and po...

(1999). Could More Health Care Lead to Worse Health? Hospital Practice: Vol. 34, No. 12, pp. 15-28.

Sequencing an individual’s DNA seems destined to become an increasingly prominent part of medical care. Once a genetic alteration has been identified and characterized by researchers, testing for it is relatively simple, requiring only white blood cells obtained via a routine blood draw. Because so many diseases are influenced by heredity, investigators are likely to identify numerous alterations associated with illness in the human genome. In the past, genetic testing concerned the next generation: decisions about whether to have a child (eg, TaySachs disease, cystic fibrosis, and Down syndrome) and screening of newborns (eg, phenylketonuria and sickle cell anemia). Increasingly, genetic testing now concerns the current generation: testing ourselves for susceptibility to chronic disease. This domain includes more common conditions (eg, heart disease, diabetes, and cancer) and a future has been promised in which medicine’s emphasis will be shifted from treatment of the sick to prevention in those at risk. 1 But the immediate future is more likely to be characterized by confusion. The confusion created by false-positive and false-negative tests will be familiar to clinicians. A less familiar source of confusion will also be present: because the absence of a genetic risk factor will rarely (if ever) reduce risk much below average, those with truly negative test results must be reminded that they remain at risk. However, the greatest challenge is what to tell those with truly positive test results. These persons may be best characterized as “pre-patients.” In this article, we examine 4 uncertainties that clinicians will have to communicate to prepatients: the nature of risk, the generalizability of risk estimates, the time at which risk information is useful, and the utility of intervention.

Objective:To determine how patients with lung cancer value the trade off between the survival benefit of chemotherapy and its toxicities. Design:Scripted interviews that included three hypothetical scenarios. Each scenario described the same patient with metastatic non-small cell lung cancer with an expected survival of 4 months without treatment. Subjects were asked to indicate the minimum survival benefit required to accept the side effects of chemotherapy in the first two scenarios (mild toxicity and severe toxicity). In the third scenario, subjects were asked to choose between chemotherapy and supportive care when the benefit of chemotherapy was either to prolong life by 3 months or to palliate symptoms. Subjects:81 patients previously treated with cis-platinum based chemotherapy for advanced non-small cell lung cancer. Main outcome measure:Survival threshold for accepting chemotherapy. Results:The minimum survival threshold for accepting the toxicity of chemotherapy varied widely in patients. Several patients would accept chemotherapy for a survival benefit of 1 week, while others would not choose chemotherapy even for a survival benefit of 24 months. The median survival threshold for accepting chemotherapy was 4.5 months for mild toxicity and 9 months for severe toxicity. When given the choice between supportive care and chemotherapy only 18 (22%) patients chose chemotherapy for a survival benefit of 3 months; 55 (68%) patients chose chemotherapy if it substantially reduced symptoms without prolonging life. Conclusions:Patients9 willingness to accept chemotherapy for the treatment of metastatic lung cancer varies widely. Many would not choose chemotherapy for its likely survival benefit of 3 months but would if it improved quality of life. The conflict between these patients9 preferences and the care they previously received has several explanations, one being that some patients had not received the treatment they would have chosen had they been fully informed.

Physician profiling is a method of cost control that focuses on patterns of care instead of on specific clinical decisions. It is one cost-control method that takes into account physicians' desire to curb the intrusion of administrative mechanisms into the clinical encounter. To provide a concrete example of profiling, we analyzed the inpatient practice patterns of physicians in Florida and Oregon.Data for 1991 from Medicare's National Claims History File were used to profile 12,720 attending physicians in Florida and 2589 in Oregon. For each attending physician, we determined the total relative value of all physicians' services delivered during each patient's hospital stay. Relative value was measured in relative-value units (RVUs), according to the resource-based relative-value scale used by Medicare in determining payments to physicians. The mean number of RVUs per admission was then adjusted for the physician's case mix according to the patients' assigned diagnosis-related groups. The influence of the physician's specialty and of selected types of services (such as imaging and endoscopy) was also examined.Florida physicians used markedly more resources, on average, than their colleagues in Oregon (46 vs. 30 case-mix-adjusted RVUs per admission). The difference was apparent for all specialties and all types of service. To illustrate the profiling data potentially available to the medical staffs of individual hospitals, we examined specific data on individual attending physicians and for various types of service for three hospitals' staffs. Despite similar overall profiles that fell below the national mean, each staff had a different practice pattern and would require different efforts to improve efficiency.In an effort to encourage further debate, we have described one method of physician profiling. Profiling data help identify and characterize differences in practice style to which individual physicians or hospital staffs can respond. Because profiling is not based on rigid rules, it is a cost-containment strategy that can easily accommodate legitimate exceptions; it is therefore preferable to methods in which the appropriateness of each clinical decision is judged separately.

Objective. —To provide an alternative to Oregon's treatment-specific approach to rationing, we propose a prioritization based on the local hospital resources invested in discretionary medical admissions. Design. —We used 1988 Oregon hospital discharge data to determine age- and sex-adjusted per-capita rates of inpatient days for discretionary medical admissions (for high-variation medical conditions) in each of 33 hospital service areas. Potential ceiling rates were defined based on prevailing utilization rates for discretionary medical admissions in each hospital service area. Savings were calculated under the assumption that resources allocated for inpatient treatment of these conditions in areas that exceed the ceiling rates were reduced accordingly. Setting. —Nonfederal, acute-care hospitals used by Oregon residents. Study population. —Oregon residents. Main Outcome Measures. —Savings were defined in terms of patient days, hospital beds, hospital charges, and average costs. Results. —Among the 16 largest hospital service areas, patient-day rates for discretionary medical admissions ranged from 188 to 335 patient days per thousand. Potential savings from applying different ceiling rates ranged from $0.4 million to $94.7 million per year. If the rate in the state capital (Salem) were used as the ceiling (218 days per thousand), then 238 beds could be closed in 20 hospital service areas, for an estimated cost savings of $47.3 million. Conclusions. —Hospital resources invested in discretionary admissions in high-rate areas represent an important potential source of funds for reallocation to meet other defined health care needs. Setting limits based on units of health care supply (eg, beds, capital equipment, and physicians) should be considered as an option for resource reallocation within health care. (JAMA. 1992;267:1925-1931)

Imagine you are watching a sunset with friends in the early 16th century. Imagine the difficulty you have in challenging their conclusion that the sun revolves around the earth because it does not ...

To the Editor. —Dr Salem-Schatz and colleagues have done admirable work investigating the influence of case-mix adjustment on physician profiles. 1 Readers should be aware, however, that case-mix adjustment may make bad apples look good. It is important to step back and consider the rationale for adjusting physician profiles in general. Adjustment is a mechanism to control for factors that confound the relationship between physician and practice style. Ideally, the intent is to remove the effect of exogenous factors (ie, those in which the physician has no influence). Age and sex adjustment serves as the classic example. On the other hand, it is important not to adjust away endogenous factors (ie, those that the physician can influence). For example, it would be silly to adjust physician profiles for physician income. In the private sector, at least, one would be adjusting for a factor that is strongly related to what one

The problem of providing health care for the uninsured has recently given rise to a number of proposals aimed at making health insurance more universally available. In the past year, national health insurance,1 a consumer-choice plan using employer-based health insurance,2 and an expansion of Medicaid known as the Health Policy Agenda3 , 4 have all been suggested. Each of these proposals devotes considerable attention to questions of cost and funding, but less attention has been given to the question of what should be purchased. This commentary focuses on the question of what coverage can be provided for the uninsured and seeks to . . .

Preview“A fascinating article with frightening implications,” remarked a primary care physician in reviewing this article. Indeed, the discovery of how antibiotic resistance is passed between bacteria has raised the specter of increasingly difficult to treat infections. Dr Welch explains how current prescribing practices contribute to the problem of antibiotic resistance and offers practical suggestions for reducing the risk.