Residency programs affected by variations in care delivered

A new generation of providers is likely to deliver the same variations in healthcare as the old unless residency programs and students commit to changing hospitals’ bad habits, according to an Oct. 31 report published by the Dartmouth Institute for Health Policy & Clinical Practice.

“Residents will learn from physicians in teaching hospitals and will model their behaviors after their faculty,” wrote Anita Arora, MD, and Alicia True, both students at the Geisel School of Medicine at Dartmouth in Hanover, N.H. “Most residency programs do not equip physicians to fully understand treatment choices and to elicit patient preferences. As residents work closely with supervising senior residents and attending physicians to develop their own clinical judgment, they will be influenced by the practice styles of their mentors and peers.

Clinical learning settings are likely to influence medical students in many different ways as there are wide variations in care delivered by different hospitals and in different regions. Where a Medicare beneficiary goes to receive care affects how much time they’re likely to spend in a hospital, their likelihood of having surgery and their rate of physician visits. Using Medicare claims data, the Dartmouth Atlas of Health Care tracks differences in hospitals’ performance against selected measures.

The project found that in the last six months of life for decedents: patients averaged 20 days in a hospital bed at NewYork-Presbyterian Hospital compared to nine at Scott & White Memorial Hospital in Temple, Texas; and patients averaged 76 physician visits at Cedars-Sinai Medical Center in Los Angeles compared to 20 at University of Utah Health Care in Salt Lake City. The project also found that per 1,000 Medicare enrollees treated between 2008 and 2010: there were 6.3 back surgeries in Nashville, Tenn., compared to 2.4 in Temple, Tex.; and 11.9 hip replacements in Salt Lake City compared to 4.3 in San Francisco.

These variations are important not just for the current generation of Medicare patients, but also for future generations as they will receive care from providers who learned and developed disparate practice styles. “Understanding variations in the way care is delivered by these institutions is important because it affects residency training and, thus, the way residents in a given program will practice as physicians,” Arora and True wrote.

Based on variations in care delivered discovered by the Dartmouth Atlas of Health Care, Arora and True suggested focusing on improvement strategies in three areas:

• Effective care, or eliminating variations in care delivered when there is a clear single best option for most patients, such as immunizations for children;
• Supply-sensitive care, or enhancing the productivity of a limited number of providers through coordinated care; and
• Practice-sensitive care, or reducing overuse through shared decision-making programs and heavier reliance on comparative-effectiveness research.

Medical students should consider these factors when choosing a residency program, Arora and True suggested. ““Physicians who train at institutions with better, more patient-centered and efficient care will be better prepared to lead the transformation of healthcare when they are in practice.”

To read the complete report, visit the Dartmouth Institute for Health Policy & Clinical Practice website.