Variation in End-of-Life Care and the Management of Chronic Illness
Data used in this report
The first section of this report deals with the treatment of patients at individual hospitals. The study population includes fee-for-service Medicare beneficiaries who died in 2010 and who were hospitalized for a chronic illness at least once during their last two years of life. This cohort was restricted to patients with at least one of nine chronic illnesses associated with high mortality rates: malignant cancer/leukemia, chronic pulmonary disease, coronary artery disease, congestive heart failure, peripheral vascular disease, severe chronic liver disease, diabetes with end organ damage, chronic renal failure, and dementia. Patients were assigned to the hospital they used most frequently during their last two years of life. If there was a tie between hospitals, the patient was assigned to the hospital associated with the last inpatient admission prior to death.
Among the variables for which the Dartmouth Atlas provides hospital-specific data, we chose those that would have the most relevant implications for a resident's training. These include:
- Hospital Care Intensity index: The index combines two measures: the number of days patients spent in the hospital and the average number of physician visits they experienced as inpatients during the last two years of life.
- Hospital days per patient, last six months of life: All days that a patient spent in acute care general hospitals during the last six months of life.
- Physician visits per patient, last six months of life: All physician visits during the patient's last six months of life, no matter where the visits occurred (in or out of the hospital).
- Percent of deaths occurring in hospital: The percent of patients assigned to the hospital that died in a hospital. The denominator is all deaths, no matter where they occurred.
- Percent of deaths that included an ICU admission: The percent of patients assigned to the hospital that died in a hospital and whose final admission included at least one stay in an intermediate- or high-intensity ICU. The denominator is all deaths, no matter where they occurred.
- Percent enrolled in hospice during the last six months of life: The percent of patients admitted into hospice during the last six months of life. Hospice is end-of-life care provided to patients who are expected to live six months or less. Pain and other symptoms of the patient's illness are treated to provide increased quality of life. Hospice care can occur at home, at an outpatient hospice center, in a hospital, or at a skilled nursing facility. These data include hospice care occurring in any of these settings.
- Percent seeing 10 or more physicians during the last six months of life: The percent of patients who saw 10 or more physicians in their last six months of life. A high rate reflects a willingness to refer patients to other physicians and may suggest fragmented care.
All of these variables were adjusted for age, sex, race, and primary chronic diagnosis.