COVER STORY

‘Geog­ra­phy is destiny’ for end-of-life care, which of­ten is costly, ag­gres­sive

Modern Healthcare - - Front Page - Mau­reen McKin­ney

Where a ter­mi­nally ill can­cer pa­tient spends his last days largely de­pends on where he lives and what hos­pi­tal he’s be­ing treated at. A study re­leased last week shows lit­tle ev­i­dence that ad­vanced can­cer treat­ment aligns with a pa­tient’s wishes. “As many as 80% of pa­tients at the end of life strongly want to be in a more home­like set­ting,” says David Good­man, left, of the Dart­mouth At­las of Health Care.

For pa­tients with ad­vanced can­cer who are near­ing the end of life, the like­li­hood that they will spend their fi­nal days in a costly hos­pi­tal in­ten­sive-care unit or at home de­pends largely on where they live and the hos­pi­tal at which they seek care.

In other words, geog­ra­phy is destiny, ac­cord­ing to David Good­man, pro­fes­sor of pe­di­atrics and health pol­icy at Dart­mouth Med­i­cal School, Hanover, N.H., and di­rec­tor of the Cen­ter for Health Pol­icy Re­search at the Dart­mouth In­sti­tute for Health Pol­icy and Clin­i­cal Prac­tice.

Good­man also is the co-prin­ci­pal in­ves­ti­ga­tor of the Dart­mouth At­las of Health Care, a long-run­ning project that uses Medi­care data to ex­am­ine vari­a­tions in the way health­care is pro­vided across the coun­try.

And in its first re­port on the qual­ity of endof-life can­cer care for Medi­care ben­e­fi­cia­ries, re­leased Nov. 16, Dart­mouth At­las re­searchers found lit­tle ev­i­dence that treat­ments are aligned with pa­tients’ wishes.

The ma­jor­ity of can­cer pa­tients would much pre­fer to re­ceive end-of-life care that al­lows for the high­est qual­ity of life and that en­ables them to live com­fort­ably, with­out pain, sup­ported by pal­lia­tive or hospice care, said Good­man, the re­port’s lead author. “That does not mean all pa­tients want that, but on av­er­age, as many as 80% of pa­tients at the end of life strongly want to be in a more home­like set­ting,” he said.

But far from re­flect­ing those pref­er­ences, the re­port—which ex­am­ined data from 235,821 Medi­care pa­tients with ad­vanced can­cer who died be­tween 2003 and 2007—found sig­nif­i­cant vari­a­tions in end-of-life care from re­gion to re­gion and from hos­pi­tal to hos­pi­tal. Roughly 29% of ad­vanced-stage can­cer pa­tients across the coun­try died in a hos­pi­tal dur­ing the three­year pe­riod, and that num­ber reached as high as 46.7% in the bor­ough of Man­hat­tan in New York City and 41.1% in Ne­wark, N.J.

That con­trasts sharply with Cincin­nati, Ohio, and Fort Laud­erdale, Fla., which had rates of 17.8% and 19.6%, re­spec­tively. And in Ma­son City, Iowa, the rate of in-hos­pi­tal can­cer deaths was only 7%.

The dis­par­i­ties per­sisted across other mea­sures as well, in­clud­ing in­ten­sive-care ad­mis­sions and chemo­ther­apy ad­min­is­tered dur­ing the last two weeks of life. About 70% of can­cer pa­tients in Detroit were hos­pi­tal­ized at least once dur­ing their last month of life, com­pared with 46.3% in San An­gelo, Texas, ac­cord­ing to the re­port. And can­cer pa­tients were far less likely to re­ceive life-sus­tain­ing treat­ments such as en­do­tra­cheal in­tu­ba­tion or CPR in the last month of life if they lived in Minneapolis

Front cover photo by Getty Im­ages

Zook says Mercy Med­i­cal Cen­ter-North Iowa makes de­ci­sions based on pa­tients’ goals.

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