The amount of money Medicare spends on chronically ill patients varies substantially from state to state, with nearly $40,000 spent per patient in New Jersey and the District of Columbia, but less than $24,000 spent in states such as Indiana and West Virginia.

Yet, there is no indication that patients in the states with the highest spending are better off than those in states with the lowest spending. In fact, the reverse seems to be true, according to researchers at Dartmouth Medical School.

Their findings, released in a report Tuesday, could have important policy implications as the nation struggles with the soaring expense of its Medicare program.

"We must fundamentally redesign the way we care for chronically ill Americans," said the authors of the report. "We must reward, rather than penalize provider organizations that successfully reduce excessive care and develop broader strategies for managing patients with chronic illness."

Researchers looked at how often Medicare patients went to the hospital during their last six months. They found that a dying person in Hawaii spends an average of 16.4 days in the hospital versus 7.3 days in Utah.

They also looked at the number of times Medicare patients went to the doctor during the last six months of life. New Jersey had the highest number of visits, 41.5. Again, Utah's Medicare patients tended to go to the doctor the least ¡ª 17 times.

Researchers did not measure whether those who died in Utah got better or worse care than patients in New Jersey. But they did try to monitor care by following three types of patients for up to five years after they suffered a heart attack, a fractured hip, or a colectomy for colon cancer.

For each illness, they found higher mortality rates for patients in the regions with the most intense care.

Dr. John E. Wennberg, director of the Center for the Evaluative Clinical Sciences at Dartmouth Medical School, said the higher mortality rates in some regions could be caused in part by medical error.

"There's a lot of concern about medical errors," Wennberg said. "If you hospitalize people twice as often in a community on a per capita basis, you have twice the risk of having a medical error problem."

Wennberg said another policy ramification for the government to consider is hospital capacity. The more hospital beds there are per capita, the greater the likelihood the patient will be admitted.

"We need to redirect resources away from acute care and invest in infrastructure that can better coordinate and integrate care outside of hospitals ¡ª for example, home health and hospice care," the report said.

The researchers concluded that the federal government could save tens of billions of dollars a year, plus improve care, if it took steps to prevent the overuse of health care.