Variation in End-of-Life Care and the Management of Chronic Illness
For chronically ill patients near the end of life, the amount of care provided varies markedly from one teaching hospital to the next. Each of these hospitals has a unique pattern of care provided to chronically ill patients; these care patterns are an important part of the training environment for residents. Fourth-year medical students may want to consider these practice styles carefully when choosing a residency program.
Table 1 reveals the wide variation in the use of physicians, hospital beds, and hospice among the 23 hospitals, which are ranked in order from the highest Hospital Care Intensity (HCI) index to the lowest. The HCI index is a measure that combines the number of days patients spent in the hospital and the average number of inpatient physician visits during the last two years of life. The highest HCI index is more than three times greater than the lowest among these medical centers. Patients who received most of their care at Cedars-Sinai Medical Center in Los Angeles saw physicians almost four times as frequently in their last six months of life compared to those who received most of their care at Scott & White Memorial Hospital in Temple, Texas. More than twice the percentage of patients treated at the University of Michigan Medical Center was enrolled in hospice in the last six months of life compared to those treated at New York-Presbyterian Hospital.
Table 1. Variation in resource utilization for chronically ill patients among 23 teaching hospitals
| Hospital |
Hospital Care Intensity (HCI) index |
Hospital days per decedent, last 6 months of life |
Physician visits per decedent, last 6 months of life |
Percent of deaths occur-
ring in hospital |
Percent of deaths assoc-
iated with ICU admis-
sion |
Percent enrolled in hospice, last 6 months of life |
Percent seeing 10 or more MDs, last 6 months of life |
| Cedars-Sinai Medical Center |
2.06 |
19.0 |
72.6 |
42.1 |
38.2 |
32.8 |
65.3 |
| NYU Langone Medical Center |
1.73 |
19.1 |
58.5 |
34.3 |
23.8 |
39.2 |
66.6 |
| Mount Sinai Medical Center |
1.50 |
18.3 |
49.1 |
44.8 |
17.0 |
23.1 |
66.3 |
| Ronald Reagan UCLA Medical Center |
1.48 |
16.8 |
49.7 |
44.1 |
40.6 |
34.2 |
62.9 |
| New York- Presbyterian Hospital |
1.37 |
20.2 |
39.1 |
44.2 |
16.2 |
24.5 |
60.9 |
| University of Pittsburgh Medical Center |
1.28 |
12.8 |
42.5 |
31.7 |
23.6 |
48.8 |
59.2 |
| Northwestern Memorial Hospital |
1.28 |
14.9 |
42.0 |
38.4 |
29.1 |
44.2 |
62.8 |
| Massachusetts General Hospital |
1.19 |
15.5 |
34.7 |
34.4 |
17.9 |
44.9 |
59.9 |
| Cleveland Clinic |
1.12 |
16.0 |
35.3 |
35.4 |
26.2 |
46.2 |
60.4 |
| Hospital of the University of Pennsylvania |
1.08 |
14.7 |
30.6 |
26.0 |
19.8 |
57.9 |
61.7 |
| University of Michigan Medical Center |
1.07 |
14.3 |
30.8 |
22.8 |
11.9 |
59.1 |
60.8 |
| Brigham and Women's Hospital |
1.06 |
14.9 |
31.5 |
34.6 |
19.4 |
41.5 |
61.5 |
| Johns Hopkins Hospital |
1.01 |
13.6 |
23.4 |
30.2 |
19.9 |
49.4 |
45.7 |
| Indiana University Health (Clarian Health) |
0.96 |
12.6 |
30.3 |
26.2 |
21.2 |
51.2 |
57.0 |
| Barnes-Jewish Hospital/ Washington University |
0.95 |
14.1 |
28.9 |
31.4 |
17.8 |
48.7 |
52.9 |
| UCSF Medical Center |
0.92 |
13.2 |
28.3 |
37.8 |
22.7 |
39.0 |
53.4 |
| Duke University Medical Center |
0.87 |
13.6 |
24.2 |
30.7 |
22.1 |
47.9 |
54.8 |
| Vanderbilt University Medical Center |
0.80 |
11.5 |
26.6 |
25.9 |
21.1 |
56.3 |
56.3 |
| University of Washington Medical Center |
0.78 |
11.3 |
22.6 |
30.2 |
20.5 |
46.9 |
53.1 |
| Stanford Hospital and Clinics |
0.78 |
11.4 |
27.0 |
38.0 |
33.1 |
44.2 |
53.1 |
| St. Mary's Hospital, Mayo Clinic |
0.70 |
9.9 |
21.3 |
22.8 |
16.8 |
44.7 |
52.4 |
| Scott & White Memorial Hospital |
0.62 |
8.9 |
19.8 |
24.9 |
15.7 |
58.1 |
42.5 |
| University of Utah Health Care |
0.62 |
8.6 |
19.7 |
23.2 |
17.0 |
55.0 |
47.2 |
| United States average |
1.00 |
11.8 |
33.7 |
28.3 |
18.2 |
47.9 |
49.5 |
Notes:
The highest value for each measure is highlighted.
Variables were adjusted for age, sex, race, and primary chronic diagnosis.
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.
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.
Hospitals are ranked in order from the highest Hospital Care Intensity (HCI) index to the lowest.
View this table for 236 teaching hospitals.
Download Excel version of this table.
The variations in hospital days and physician visits are also shown in Figures 1 and 2. In these charts, the 23 hospitals are displayed as red dots on a background of 236 teaching hospitals throughout the nation. These charts demonstrate that the 23 medical centers reflect the variation in care present at teaching hospitals nationwide.
Figure 1. Average number of hospital days per chronically ill Medicare patient during the last six months of life among patients receiving most of their care at teaching hospitals (2010 deaths)
Figure 2. Average number of physician per chronically ill Medicare patient during the last six months of life among patients receiving most of their care at teaching hospitals (2010 deaths)
