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Dartmouth Atlas: Costs Rise for Medicare Patients at End of Life

 |  By John Commins  
   April 13, 2011

Chronically ill Medicare patients spent fewer days in the hospital and received more hospice care in 2007 than they did in 2003. Patients who were hospitalized, however, got more aggressive, intensive, and costly care, according to a new Dartmouth Atlas Project report on end-of-life care.

The study -- Trends and Variation in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness – was released Tuesday and found that Medicare patients diagnosed with severe chronic illness were less likely to die in a hospital and more likely to receive hospice care. They also had many more visits from physicians, particularly medical specialists, and spent more days in ICUs.

"In addition to its effects on patients' quality of life, unnecessarily aggressive care carries a high

financial cost. About one-fourth of all Medicare spending goes to pay for the care of patients in their last year of life, and much of the growth in Medicare spending is the result of the high cost of treating chronic disease," said David C. Goodman, MD, lead author of the report, in a media release.

"It may be possible to reduce spending, while also improving the quality of care, by ensuring that patient preferences are more closely followed," said Goodman, a co-principal investigator for the Dartmouth Atlas Project, and director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice.

The report documents trends from 2003 to 2007 in the use of medical resources to treat Medicare patients at the end of life at hospital referral regions and at 94 academic medical centers.

Geography continues to play a huge role, the report found, noting that care patients received in the months before they died depended largely on where they lived, and widespread variations persist. Even at academic medical centers, patients' end-of-life experiences differ greatly. Most academic medical centers substantially changed the intensity of the end-of-life care they provided from 2003 to 2007, but not in the same direction. Some provided more. Some provided less.

The report found that:
  • From 2003 to 2007, the percentage of chronically ill patients dying in hospitals and the average number of days they spent in the hospital before their deaths declined in most parts of the country and at most academic medical centers. In 2003, 32.2% of patients died in a hospital; by 2007, the rate had dropped to 28.1%. In 2007, the highest rates of hospital deaths were in and around New York City, including Manhattan (45.8%), East Long Island (41.9%) and the Bronx (39.9%). Chronically ill patients were far less likely to die in a hospital in Minot, ND (12%), Fort Lauderdale, FL (19%) and Portland, OR (19.6%).
  • For patients using academic medical centers for most of their care, rates of hospital deaths also dropped. Several hospitals that had among the lowest rates in 2003 saw substantial decreases over the five-year period; one example is University of Utah Health Care in Salt Lake City, where the rate dropped from 31.5% to 21.3%. In comparison, in 2003, UCLA Medical Center and the Medical College of Georgia in Augusta had very similar rates, at 39.1% and 39.7%, respectively. Over five years, their rates moved in opposite directions. UCLA joined medical centers with the highest rates at 45.5%, while the rate at the Medical College of Georgia dropped to 28.7%.
  • Overall, the average patient spent slightly fewer days in the hospital during the last six months of life in 2007 than in 2003. The national rate dropped from 11.3 to 10.9 hospital days per patient. In 2007, chronically-ill patients in Manhattan spent, on average, 20.6 days in the hospital during their last six months of life, almost four times more than patients in Ogden, UT, where the average was 5.2 days.
  • Those academic medical centers where patients spent less time in the hospital in 2007 than in 2003 included the University of Texas Medical Branch Hospitals in Galveston (-5.0 days), the University of Iowa Hospitals and Clinics in Iowa City (-5.0 days) and Tufts-New England Medical Center in Boston (-4.6 days). Ten academic medical centers had increases of at least two days, including Hahnemann University Hospital in Philadelphia (+6.8 days).
  • Chronically ill patients were significantly more likely to be treated by 10 or more doctors in the last six months of life in 2007 than they were in 2003, as the national rate increased from 30.8% to 36.1%. In 2007, patients in Royal Oak, MI received the most intensive care by this measure, with 58.1% of patients seeing 10 or more doctors in the last six months of life. Other regions with high rates included Ridgewood, NJ (57.6%) and Philadelphia (57.2%). Regions with low rates included Boise, ID (14.2%), Salt Lake City (15.0%) and Medford, OR (16.4%).
  • From 2003 to 2007, among the 35 academic medical centers for which data are available, 22 had increases in the percentage of patients seeing 10 or more doctors in the last six months of life. Emory University Hospital saw the largest growth in this rate, from 40.4% to 63.2%, while the University of North Carolina Hospitals in Chapel Hill had the largest decrease, from 45% to 35.2%. In 2003, the likelihood that a patient at Emory University Hospital would see 10 or more doctors was similar to that for a patient at the University of North Carolina Hospitals. Over the next five years, the percentage of patients seeing 10 or more doctors increased 22.8 percentage points at Emory, while the percentage dropped 9.8 percentage points at UNC Hospitals.

 

"The differences observed across regions and academic medical centers in the approach to caring for patients with chronic illness underscore important opportunities to learn how to improve end-of-life care," said Elliott S. Fisher, MD, report author and co-principal investigator of the Dartmouth Atlas Project, in a media release. "While current trends demonstrate that change is occurring in many regions and at many institutions, it is not always in the direction that patients may prefer."

Fisher, who is also the director of the Center for Population Health at the Dartmouth Institute for Health Care Policy and Clinical Practice, said more work needs to be done "to ensure that future variation in care reflects the well-informed preferences of patients."

The researchers said variations in the treatment of chronically-ill Medicare patients depend largely on the systems of care within different regions and hospitals. For example, declines in the rates of death in a hospital and of death associated with admission to intensive care may also be evidence of attempts to provide care that aligns more closely with many patients' preferences. But not all hospitals changed at the same pace.

Furthermore, the number of ICU days in the last six months of life increased both nationally and in most hospitals and regions; so, too, did the amount of physician labor used.

The full report may be viewed here.

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

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