"An Ounce of Prevention" Not Given Enough Weight in the U.S. Heath Care System, New Report Shows

Mammography, Colorectal Cancer Screening and Diabetic Preventive Services Examined

SAN FRANCISCO � Despite the known benefits of such preventive services as screening for breast cancer and eye exams for diabetics, a large proportion of senior citizens are not receiving this type of care, according to a new report. The Quality of Medical Care in the United States: A Report on the Medicare Program, the third national release of the Dartmouth Atlas of Health Care, shows that even though the Medicare program pays for these tests, and panels of experts have documented their effectiveness in preventing complications and premature deaths, compliance with the recommended tests is extremely erratic. For example, in some parts of the country as few as 12.5 percent of elderly women receive recommended annual mammograms.

"We should be striving for close to 100 percent use of these specific preventive services considering what we know about prevention and early detection, but we are nowhere near that goal," said the Atlas' principal investigator, John E. Wennberg, M.D., M.P.H., of the Dartmouth Medical School. "Prevention of complications and early detection of treatable disease are among the most important goals of medicine and should be a top priority for the health care field."

"Preventing disease using reliable screening methods should be a no-brainer � and most importantly, Americans want these benefits," said Jonathan T. Lord, M.D., chief operating officer and quality expert at the American Hospital Association (AHA). "Physicians and other providers should see these data as an opportunity to make improvements and to work together with their patients to make sure everyone is receiving what are often life-saving preventive services." The AHA subsidiary Health Forum publishes the Atlas.

Highlights include the following:

• Screening for breast cancer: Mammograms are recommended at least once every two years for women age 65-69. However, in 1995-96, only 28.3 percent of women in this age group received at least one mammogram; compliance with recommended guidelines varied from a low of 12 percent to a high of 50 percent. Women in the Northeast, Florida and Michigan were more likely to receive mammography than women elsewhere.
• Screening for colorectal cancer: Screening by either fecal occult blood test or colonoscopy is recommended annually, but on average, only 12 percent of the 29.4 million Americans enrolled in Medicare in 1995-96 received one preventive test. Compliance with the screening was higher in the Northeast and Southeast.
• Immunization for pneumococcal pneumonia: Vaccinations every 10 years are advised for the elderly, but the rates for those receiving the vaccine ranged from nine to 38 percent.
• Preventive services for diabetics: About 1.7 million Medicare patients with diabetes are "underserved," according to the Atlas. Because of complications that can result from the disease, annual eye exams, annual monitoring of glucose markers, and semi-annual cholesterol readings are recommended. Percentages of the population receiving the eye exam annually ranged from 25 to 60 percent.

"How preventive services are used seems to reflect local physicians� opinions and practice styles," Wennberg says. "The underuse of these services and the haphazard nature of compliance with recommended guidelines indicate there is substantial opportunity to improve the quality of care. The �cure� appears to be better management of resources, rather than more spending."

In addition to findings on preventive services, the 1999 Atlas continues to show wide geographic variation in the numbers and types of physicians, surgical procedures, hospital beds and Medicare dollars spent on various procedures. For example, residents of some parts of the country are as much as 10 times more likely to receive particular surgical procedures than people with the same disease who live elsewhere. The Atlas shows variation in 10 surgical procedures � repair of hip fracture, colectomy for colorectal cancer, cholecystectomy, angioplasty, coronary artery bypass surgery, hip replacement, lower extremity bypass surgery, carotid endarterectomy, back surgery and radical prostatectomy � representing approximately 42 percent of surgeries received by Medicare patients.

Last year�s Atlas revealed that the American experience with death varied greatly from one community to the next, which the 1999 Atlas confirms. The Atlas explored the "intensity of care in the last six months of life" showing the number of physicians involved in patients� care varied substantially. In some regions, more than 30 percent of patients saw 10 or more physicians during their last six months while in others fewer than three percent were treated by that many different physicians.

"The Atlas once again raises questions about what level and type of health care is right for our country, and it presents an opportunity for health care leaders to create change in the system for everyone=s benefit,@ said Steven A. Schroeder, M.D., president of the Robert Wood Johnson Foundation, which funded the Dartmouth research.

The 1999 Dartmouth Atlas is based on research by Dartmouth medical epidemiologist Wennberg and colleagues at the Center for the Evaluative Clinical Sciences. It is a volume of text, graphs and maps showing the geographic distribution of health care resources in the United States based on how health care is used by defined populations, rather than the physical location of health care resources. The Dartmouth Atlas data are based on 1995-96 Medicare statistics and other health care databases.

Dartmouth research identified 3,436 hospital service areas in the United States, and 306 hospital referral regions -- aggregates of hospital service areas that are the natural markets for tertiary care such as open heart surgery and neurosurgery. Dartmouth researchers used the technique called "small area analysis" to compare different populations= consumption of health care services, taking into account the difference in populations= composition by age, sex, race and other factors that affect demand for health care.

The Atlas findings are already being used by employers. The AHA and the Midwest Business Group on Health recently released a study, funded by the Robert Wood Johnson Foundation, on how employers will use the Dartmouth Atlas to make sure the health care services their employees receive are effective. As a result of the study, physicians in these groups are working more closely with colleagues from different cities and are working more directly with patients to involve them in the decision-making process about their health care treatment choices.

State hospital associations are beginning to develop state versions of the national Atlas that go beyond Medicare data and compare patients in all age categories. The Hospital and Healthsystem Association of Pennsylvania recently published the Dartmouth Atlas of Health Care in Pennsylvania. And atlases specific to surgical specialties - cardiovascular, orthopedic and vascular surgery -- are in development.

The Center for the Evaluative Clinical Sciences at Dartmouth is a multidisciplinary group of researchers � epidemiologists, economists, clinicians, statisticians, sociologists and others � investigating a variety of issues related to medical care and its outcomes.

The American Hospital Association is a not-for-profit association of health care provider organizations and individuals that are committed to health improvement of their communities. The AHA is the national advocate for its members, which includes 5,000 hospitals, health care systems, networks, and other providers of care, and 37,000 individuals. Founded in 1898, the AHA provides education for health care leaders and is a source of information on health care issues and trends. For more information, visit the AHA web site at www.aha.org.

The Robert Wood Johnson Foundation, based in Princeton, N.J., is the nation's largest philanthropy devoted exclusively to health and health care. The Foundation concentrates its grantmaking in three areas: (1) to ensure that all Americans have access to basic health care at reasonable cost; (2) to improve care and support for people with chronic health conditions; and (3) to reduce the personal, social and economic harm caused by substance abuse � tobacco, alcohol and illicit drugs.

The Dartmouth Atlas of Health Care is available in hardcover (catalog #044401) for $295 for AHA members; $350 for non-members; in a Data Viewer on CD-ROM (catalog #044452) for $1,095 for AHA members; $1,295 non-members; a package of both the book and CD-ROM (catalog #044453) are available for $1195 for AHA members; $1395 non-members. Order by calling 800-AHA-2626.

For more informatin, contact: Carol Schadelbauer, AHA, (202) 626-2342 or Alicia Mitchell, AHA (202) 626-2339

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