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Cancer Care for Dying Patients On The Rise

 |  By cclark@healthleadersmedia.com  
   September 05, 2013

Conflating disease treatment with patient care against a backdrop of a fee-for-service reimbursement system is leading to more aggressive treatments for terminally ill oncology patients, research conducted for the Dartmouth Atlas Project suggests.

Cancer care for seniors at the end of life has become more aggressive—and less in line with patients' desires—than it was between 2003 and 2007, according to the latest edition of the Dartmouth Atlas Project [PDF].

There are, however, some encouraging signs, noted the project's David Goodman, MD, co-principal investigator, said during a news teleconference Wednesday.

Medicare beneficiaries with advanced cancer overall spent less time in the hospital and more received hospice care between 2010 and 200 –2007, the two periods studied. "But even as hospice care was increasing, most of the additional hospice days (in 2010) were in the final three days of life, a period when it's really too late to provide much benefit to the patient and family," he said.

Additionally, the average number of days these patients spent in the intensive care unit increased by 21% and 27% more patients received care from 10 or more physicians, between the two study periods, "generally considered a sign of fragmentation of care."

But the most important finding from the latest analysis, Goodman said, was the wide variation, or what he describes as the "striking differences in the pace and even the direction of change across hospitals."

For example, while both Allegheny General Hospital in Pittsburgh and Georgetown University Hospital in Washington, D.C. had similar percentages (38%) of patients who died of their cancers while hospitalized, not a desirable goal, "by 2010, rates moved in opposite directions.

Georgetown joined a group of medical centers with the highest rates of death in the hospital, 42%, (while) the rate at Allegheny General Hospital dropped to about 17%," Goodman said.

Likewise, at Northshore University HealthSystem's Evanston Hospital outside Chicago in 2010, 10% of cancer patients who died had chemotherapy in the last two weeks of life in 2010, which was a steep increase from 4% in the 2003-2007 period studied.

To illustrate that this is not just a practice in suburban Chicago, Goodman added that Advocate Lutheran General Hospital in nearby Park Ridge saw chemotherapy use in the last two weeks drop, from 10% to 6%.

The issue is of critical importance because more than 500,000 people in the United States die each year from cancer, at great cost to the healthcare system.

Ira Byock, MD, director of palliative medicine at Dartmouth-Hitchcock Medical Center, blamed the trend in part on the fee-for-service reimbursement system, "which is procedure-based and treatment-based, and is permissive of the trends we're seeing."

"Because the reimbursement system, in this case Medicare, continues to say 'yes' to more disease treatment, there is no pressure from the reimbursement process to have patients, families, or their physicians say, 'Wait a minute. This is not in the patient's best interest.' "

He also believes that healthcare providers, patients and their families are conflating "two different concepts… disease treatment and patient care.

"We doctors want our patients to live as long and well as possible. But there is some confusion about what is the best treatment for the disease is, and what is the best care for a person living with cancer is.

"I don't think there's ill intention… but in trying to give the very best attention to patients and families, there is the [tendency] to put more and more intensive and aggressive disease treatment in place when what people really need is the best care."

"At some point in time, as incurable cancer progresses, more treatment does not equal better care," Byock said.

Byock elaborated on generally accepted guidelines and endorsed measures for cancer care. For example, he says, for a patient with advanced non small cell lung cancer, after the third round of chemotherapy if the cancer continues to progress, "further cytotoxic chemotherapy is not in the patient's best interest, and outside of a formal clinical trial it should not be given.

"But right now, the reimbursement system will pay for that, even though retrospectively we would say that care is outside published best practice guidelines and should never have been given."

Among the report's other key points:

Hospital Deaths: Nationally, the percent of cancer patients who died in the hospital decreased more than 4 percentage points, from an average of 28.8% during a period between 2003 and 2007 to 24.7% of patients in 2010. More patients, 54.6% to 61.3% were enrolled in hospice in the last month of life.

ICU Care: The percentage of patients admitted to a hospital ICU during the last month of life went from 23.7% to 28.8% during these two reviewed periods, and the percentage of patients who were placed on hospice during their last three days of life increased from 8.3% to 10.9%, which meant there was less opportunity for meaningful palliative care.

Multiple MDs: The percent of patients treated by 10 or more physicians during their last six months of life went from 46.2% to 58.5%, suggesting more rather than less fragmentation of their care.

Lifesaving measures: The use of treatments such as endotracheal intubation, feeding tube placement, and cardiopulmonary resuscitation during the patients' last month of life remained unchanged. And the average percentage of patients who received chemotherapy in the two weeks before their deaths was unchanged.

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