Dartmouth Atlas: Evidence-based, Coordinated Care for Seniors Elusive

Three areas where the use of evidence-base care is particularly lacking are prostate cancer screenings, breast cancer screenings, and feeding tube placement for Medicare recipients with advanced dementia.

Medicare beneficiaries with multiple chronic conditions spend what amounts to one month each year in a doctor's office, hospital, or some other healthcare venue but often do not receive well-coordinated or evidence-based care, according to a new study from the Dartmouth Atlas Project.

"Our healthcare system is fantastically designed to provide skilled and specialized care and is able to rally the best technology to cure diseases," study lead author Julie P.W. Bynum, MD, associate professor of The Dartmouth Institute for Health Policy & Clinical Practice, told reporters in a conference call Wednesday.

"For older age groups, the problem is not curing a single disease but managing multiple diseases and helping people to live as well as they can as their health status changes, and their life expectancy declines."

Using Medicare enrollment and claims data from 2012, Bynum's report identifies where the nation is making progress in patient-centered care and where improvements need to be made for older adults, a population that will grow from 43.1 million in 2012 to 83.7 million by 2050.

In 2012, the average Medicare beneficiary was in contact with the healthcare system on 17 days, and 33 days if they had two or more chronic conditions. The results varied significantly from region to region within the 306 hospital referral regions identified by the Dartmouth Atlas. For example, Medicare beneficiaries in East Long Island and Manhattan, spent 24.9 and 24.6 days, respectively, in contact with the healthcare system, while patients in Marquette, MI, and Lebanon, NH, only spent 10.3 and 10.2 days, respectively, the report showed.

For patients with multiple chronic conditions and dementia, Manhattan and East Long Island tied for the highest rate of contact days among patients with two or more chronic conditions, at 46.2 days. Patients in East Long Island also had the highest rate of contact days among patients with dementia, at 44.9 days, the report said.

"It's often a joke that with elderly people all they want to talk about is their healthcare, but healthcare has become a substitute for their social life," Bynum says. "That may be a joke, but these numbers should give us pause to ask whether as an older adult or a family member if we want to spend our time this way, shuttling back and forth between visits and lab tests? Would it be possible to organize our care such that we can reclaim some of those days to take care of ourselves?"

The report shows that only 57% of Medicare beneficiaries in 2012 had a primary care physician as their predominant provider of care—the healthcare professional with whom the person has the most outpatient visits. This trend continues despite evidence that primary care physicians can lower costs and reduce avoidable hospitalizations.

Specialists and Unnecessary Care
"Forty percent of older adults see a subspecialist such as a cardiologist or an oncologist as their predominant provider. In some areas of the country, such as Louisiana and Mississippi, 60% of people sought specialists most often," Bynum says.

"It's unclear whether the specialists view themselves as providing the coordinating services typically associated with primary care, or whether the patients think of them as a primary care doctor, but this is an important caution for healthcare systems and policy makers as we start to reorganize care around primary care specialties."

Bynum noted three areas where the use of evidence-base care was particularly lacking, including prostate cancer screenings, breast cancer screenings, and feeding tube placement for people with advanced dementia.

With prostate-specific antigen screenings, for example, the national average rate among older men, ages 75 and older, was 19.5%, and regional discrepancies were significant, from 9.9% in Casper, WY, to 30% in Miami, even though the American Cancer Society and the American Urological Association recommend against PSA tests for older men.

With breast cancer screenings, the Dartmouth Atlas found that the national average rate of screening for mammography for woman age 75 and older was 24.2%, even though the screenings are not recommended by the U.S. Preventive Services Task Force. The rates varied from 15.3% in Miami, to 37.2% in Sun City, AZ.

On positive fronts, the report showed that adherence to diabetes testing guidelines increased by 10% in 2012 when compared with data from 2003-05.

The biggest improvement, however, came from preventable hospital admissions, which fell 23% from 5.5% of Medicare beneficiaries in 2003 to 4.2% in 2012. The rates declined in nearly every hospital referral area but varied threefold, from 2.2% in San Mateo County and San Luis Obispo, CA, to 7.3% in Monroe, LA.