Hospital Use and Survival among Veterans Affairs Beneficiaries
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《新英格兰医药杂志》
To the Editor: Ashton et al. (Oct. 23 issue)1 present a series of analyses of time trends in survival among Veterans Affairs (VA) beneficiaries with chronic conditions without considering how survival has varied among other chronically ill patients. A more informative approach might be to use the existing literature and assess survival rates reported for patients with various conditions in comparison with those for VA beneficiaries. Such estimates indicate that VA beneficiaries with diabetes are doing as well as the general population with the same disease,2 that those with congestive heart failure are doing considerably better,3 that those with pneumonia are doing slightly worse,4 and that those with chronic renal disease are doing considerably worse5 (Table 1). Of course, it could be that the adjustments in the authors' analyses1 explain these discrepancies, but some sort of comparison with chronically ill Americans outside the VA system would be helpful. Knowledge of how the inclusion of "healthy survivors" might bias each of these survival rates and how treatment and hospitalization may vary according to the condition and time would improve our understanding of whether declining hospital use had any serious consequences for chronically ill VA beneficiaries.
Table 1. Comparison of the 1996 One-Year Survival Rates Reported by Ashton et al. with Other Estimates of the One-Year Survival Rate for a Given Condition.
Karen C. Swallen, M.P.H., Ph.D.
University of Wisconsin
Madison, WI 53706
kswallen@ssc.wisc.edu
References
Ashton CM, Souchek J, Petersen NJ, et al. Hospital use and survival among Veterans Affairs beneficiaries. N Engl J Med 2003;349:1637-1646.
Thomas RJ, Palumbo PJ, Melton LJ III, et al. Trends in the mortality burden associated with diabetes mellitus: a population-based study in Rochester, Minn., 1970-1994. Arch Intern Med 2003;163:445-451.
Marston BJ, Plouffe JF, File TM Jr, et al. Incidence of community-acquired pneumonia requiring hospitalization: results of a population-based active surveillance study in Ohio. Arch Intern Med 1997;157:1709-1718.
Levy D, Kenchaiah S, Larson MG, et al. Long-term trends in the incidence of and survival with heart failure. N Engl J Med 2002;347:1397-1402.
Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 1999;341:1725-1730.
To the Editor: In his editorial, Fisher1 argues that there may be an inverse relationship between quality and quantity in health care. However, I believe that the improved clinical outcomes in the VA study resulted not from lower expenditures but rather from a third set of changes, including increased integration of facilities, creation of new centers of excellence, and implementation of an advanced information-technology system.
It has been shown that comprehensive health care systems provide superior outcomes with respect to quality and encourage more efficient use of resources. For example, in California, the physicians of Kaiser Permanente have lowered the mortality from cardiovascular disease among their patients to 30 percent below that among patients in the surrounding community,2 while providing care at a relatively low cost.3 Superior quality is attained not by doing less, but by implementing integrated systems of care, supported by advanced information-technology systems. Whereas the VA could do this by directive, accomplishing this important goal will prove more difficult for the nation as a whole.
Robert Pearl, M.D.
Permanente Medical Group
Oakland, CA 94612
References
Fisher ES. Medical care: is more always better? N Engl J Med 2003;349:1665-1667.
Making a difference: recognizing and rewarding excellence. Annual report 2002. Washington, D.C.: National Committee for Quality Assurance, 2003.
Hewitt Health Value Initiative. Lincolnshire, Ill.: Hewitt, 2003.
Dr. Fisher replies: The evidence supports Dr. Pearl's assertion that the adoption of an integrated approach to care is a path toward improving the quality of care for patients with chronic disease.1 We should not kid ourselves, however, by assuming that the adoption of such models will provide cost savings in and of themselves. The local capacity of the health care system is the major determinant of overall utilization.2 Unless beds are closed, or physicians laid off, reduced utilization by those enrolled in a management program for chronic disease will lead to compensatory increases in utilization by other patients. It is little wonder that constraints on capacity are the means whereby both the VA and staff-model health maintenance organizations such as Kaiser Permanente have achieved their efficiency.3
Moreover, the additional utilization among residents of high-capacity regions in the United States is devoted to services that do not appear to improve health or the quality of care and that may make things worse.4,5 But integration is not enough. Until we address the challenge posed by the overuse of supply-sensitive services, we are unlikely to achieve both the quality and efficiency achieved by systems such as Kaiser Permanente.
Elliott Fisher, M.D., M.P.H.
Veterans Affairs Outcomes Group
White River Junction, VT 05009
References
Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model. JAMA 2002;288:1909-1914. [Abstract/Full Text]
Fisher ES, Wennberg JE, Stukel TA, Sharp SM. Hospital readmission rates for cohorts of Medicare beneficiaries in Boston and New Haven. N Engl J Med 1994;331:989-995.
Kronick R, Goodman DC, Wennberg J, Wagner E. The marketplace in health care reform: the demographic limitations of managed competition. N Engl J Med 1993;328:148-152.
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. 1. The content, quality, and accessibility of care. Ann Intern Med 2003;138:273-287.
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. 2. Health outcomes and satisfaction with care. Ann Intern Med 2003;138:288-298.
Table 1. Comparison of the 1996 One-Year Survival Rates Reported by Ashton et al. with Other Estimates of the One-Year Survival Rate for a Given Condition.
Karen C. Swallen, M.P.H., Ph.D.
University of Wisconsin
Madison, WI 53706
kswallen@ssc.wisc.edu
References
Ashton CM, Souchek J, Petersen NJ, et al. Hospital use and survival among Veterans Affairs beneficiaries. N Engl J Med 2003;349:1637-1646.
Thomas RJ, Palumbo PJ, Melton LJ III, et al. Trends in the mortality burden associated with diabetes mellitus: a population-based study in Rochester, Minn., 1970-1994. Arch Intern Med 2003;163:445-451.
Marston BJ, Plouffe JF, File TM Jr, et al. Incidence of community-acquired pneumonia requiring hospitalization: results of a population-based active surveillance study in Ohio. Arch Intern Med 1997;157:1709-1718.
Levy D, Kenchaiah S, Larson MG, et al. Long-term trends in the incidence of and survival with heart failure. N Engl J Med 2002;347:1397-1402.
Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 1999;341:1725-1730.
To the Editor: In his editorial, Fisher1 argues that there may be an inverse relationship between quality and quantity in health care. However, I believe that the improved clinical outcomes in the VA study resulted not from lower expenditures but rather from a third set of changes, including increased integration of facilities, creation of new centers of excellence, and implementation of an advanced information-technology system.
It has been shown that comprehensive health care systems provide superior outcomes with respect to quality and encourage more efficient use of resources. For example, in California, the physicians of Kaiser Permanente have lowered the mortality from cardiovascular disease among their patients to 30 percent below that among patients in the surrounding community,2 while providing care at a relatively low cost.3 Superior quality is attained not by doing less, but by implementing integrated systems of care, supported by advanced information-technology systems. Whereas the VA could do this by directive, accomplishing this important goal will prove more difficult for the nation as a whole.
Robert Pearl, M.D.
Permanente Medical Group
Oakland, CA 94612
References
Fisher ES. Medical care: is more always better? N Engl J Med 2003;349:1665-1667.
Making a difference: recognizing and rewarding excellence. Annual report 2002. Washington, D.C.: National Committee for Quality Assurance, 2003.
Hewitt Health Value Initiative. Lincolnshire, Ill.: Hewitt, 2003.
Dr. Fisher replies: The evidence supports Dr. Pearl's assertion that the adoption of an integrated approach to care is a path toward improving the quality of care for patients with chronic disease.1 We should not kid ourselves, however, by assuming that the adoption of such models will provide cost savings in and of themselves. The local capacity of the health care system is the major determinant of overall utilization.2 Unless beds are closed, or physicians laid off, reduced utilization by those enrolled in a management program for chronic disease will lead to compensatory increases in utilization by other patients. It is little wonder that constraints on capacity are the means whereby both the VA and staff-model health maintenance organizations such as Kaiser Permanente have achieved their efficiency.3
Moreover, the additional utilization among residents of high-capacity regions in the United States is devoted to services that do not appear to improve health or the quality of care and that may make things worse.4,5 But integration is not enough. Until we address the challenge posed by the overuse of supply-sensitive services, we are unlikely to achieve both the quality and efficiency achieved by systems such as Kaiser Permanente.
Elliott Fisher, M.D., M.P.H.
Veterans Affairs Outcomes Group
White River Junction, VT 05009
References
Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model. JAMA 2002;288:1909-1914. [Abstract/Full Text]
Fisher ES, Wennberg JE, Stukel TA, Sharp SM. Hospital readmission rates for cohorts of Medicare beneficiaries in Boston and New Haven. N Engl J Med 1994;331:989-995.
Kronick R, Goodman DC, Wennberg J, Wagner E. The marketplace in health care reform: the demographic limitations of managed competition. N Engl J Med 1993;328:148-152.
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. 1. The content, quality, and accessibility of care. Ann Intern Med 2003;138:273-287.
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. 2. Health outcomes and satisfaction with care. Ann Intern Med 2003;138:288-298.