Dartmouth College researchers report healthcare disparities

SAS® analysis helps uncover wasteful spending

Dartmouth researchers estimate that up to 30 percent of Medicare dollars are wasted each year. Their groundbreaking studies on regional variation in Medicare spending, resource allocation and utilization are reshaping the way medicine is practiced and how Medicare pays providers. The interactive database that compares the efficiency of more than 4,000 hospitals in the US is powered by SAS.

For the last 15 years, the Dartmouth Atlas Project has focused on accurately describing the distribution and consumption of medical resources in the United States. Using SAS software to analyze data from large healthcare claims databases, researchers at the Dartmouth Institute for Health Policy and Clinical Practice in New Hampshire can compare thousands of US hospitals. The resulting series of Atlas publications documents marked differences in how Americans use healthcare resources and how local resource supplies can influence rates of healthcare consumption.

Funded by the Robert Wood Johnson Foundation, research from the project has been presented in peer-reviewed journals, including the Journal of the American Medical Association and the New England Journal of Medicine, premier national and leading local media outlets such as The New York Times, The Wall Street Journal, The Washington Post, USA Today and ABC News, and to the US Congress. Policymakers, journalists and the general public can access the study’s findings online at www.dartmouthatlas.org, where browsers can view hospitals by metropolitan region. You may have read about Medicare patients in Elyria, OH, getting angioplasties performed at a rate four times the national average; that data – and much more – was pulled together by the Atlas project.

The data has also played a role in medical fraud investigations in California and Louisiana. In California, patient complaints led to an FBI investigation in 2002 of doctors at Redding Medical Center. Atlas project data showed that this hospital stood out as having the highest rate of heart bypass surgeries among Medicare benefactors in the nation.

The project’s researchers don’t just look at usage, but also at the quality of care, showing over and over again that quantity doesn’t produce quality. In its recent study focusing on end-of-life care, researchers discovered:

• The average number of hospitalized days during the last six months of life ranged from 12.0 days per decedent at St. Mary’s Hospital (the principal Mayo Clinic hospital in Rochester, MN) to 22.7 at New York-Presbyterian Hospital. 
• The University of California – Los Angeles has the highest number of days in intensive care units during the last six months of life (11.6 days per decedent), a rate 3.5 times higher than the rate for patients treated at the University of California’s teaching hospital in San Francisco (3.4 days per decedent).

All of these hospitals are highly regarded. What Dartmouth researchers found is the hospitals with higher usage rates have more specialists and beds, but they don’t have better outcomes – or better patient satisfaction – than those hospitals with much lower utilization.

If information is power, the Dartmouth Atlas Project’s research may empower healthcare consumers to become better informed about the care they receive – and propel changes in the way healthcare is paid for to help keep programs like Medicare solvent. “Higher spending doesn't lead to better quality or outcomes,” says Elliott Fisher, MD, Director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice. “We found no evidence that a higher-intensity pattern of care leads to better survival. Some patients benefit, but just as many or more may be harmed.”

The end-of-life study came from data of 4.7 million Medicare enrollees who died from 2001 to 2005 and had at least one chronic illness. It showed that Medicare could have saved $50 billion if all US hospitals adhered to the high-quality, low-cost standard set by hospitals in the Salt Lake City region.

“The majority of acute care hospitals are applying their standard forms of ‘rescue medicine’ to people who are in advanced stages of diseases that can’t be cured,’’ says principal investigator John E. Wennberg, MD, MPH. “Patients don’t benefit – they can’t be rescued – and the costs of such care are very high, both in dollars spent and in providing care that the majority of chronically ill patients might not want, such as admissions to intensive care and being sent to specialist after specialist.”

SAS®: The gold standard for analyzing healthcare data
Dartmouth researchers rely on nearly three terabytes of claims data available from Medicare. “We have found that the Medicare data is a very good indicator of what’s going on with the population as a whole,” says Kristen Bronner, Editor of the Dartmouth Atlas. “Research using private insurance and state discharge data in California, Michigan, Virginia and Pennsylvania has shown that the patterns we observe in fee-for-service Medicare are highly correlated with younger populations, as well as Medicare enrollees covered by HMOs.”

Stephanie Raymond, Senior Programmer with the Atlas project, uses SAS software to extract event-defining information from the Medicare data. She then summarizes those events by geography to measure healthcare usage rates throughout the country. 

“For most of the folks I’ve worked with in healthcare research, SAS is their gold standard,” Raymond says. “We can do all the data management and data manipulation that we need, as well as the heavy analytics.”

In particular, Raymond praises SAS for its speed and flexibility. She was able to create a process to automatically extract descriptive elements that define Medicare claim data, transform that into SAS code and load the claim data in SAS data sets. “I like SAS for its versatility in handling and managing data,” she says. “SAS handles really huge files very nicely, and SAS makes it very easy for me to process multiple years of data and multiple file segments. We try to use all the tips, tricks and techniques SAS has to offer to efficiently process the claims data. Features and improvements with SAS 9, especially use of multithreading across multiple processors, saves time and resources.”

Raymond’s results are used by Dartmouth faculty members for numerous projects, including the books and reports in the Atlas series, the Atlas project Web site and ongoing research projects that recommend long-term changes in healthcare practices and Medicare spending.

Overall, Raymond says, “We’re definitely getting our money’s worth from SAS. It provides access to an incredible amount of information.”

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