Saturday, September 27, 2008

Hospital Palliative Performance Profiles, part 2

I'm often asked to describe the key elements behind the success of Advanced Palliative Care Organizations, and to cite specific examples across the country. Similarly, I'm asked how we determine the performance of communities and hospitals around palliative care. Simply put, we use the Dartmouth Medical Atlas, and seven outcome measures in the study considered by those whose palliative care knowledge I hold in high regard to be reliable indicators of the prevailing end-of-life care practices of hospitals and communities. These measures relate to place of death, referrals to hospice, use of intensive and acute hospital care during the final six months of life, and the coordination of physician care during those final months.
We then examine the hospital's performance in these palliative outcome measures, against local, state, and national performance data. Hospitals are assigned points based upon their performance against these standards, which when aggregated reflect their Palliative Performance Score. Hospitals are then graded, as follows, based upon their score.

100 - plus A best practice, exemplar
75-99 B solid performance, commendable, aspiring leader
50-74 C common performance, middle-of-the-road
25-49 D below-average performance, needs considerable improvement
less than 25 E complete overhaul necessary of current practices

Curious about your hospital(s) performance in palliative care? Drop me a line at

Friday, September 26, 2008

Hospital Palliative Performance Profiles

Since 1996, the Dartmouth Atlas of Health Care has tracked patterns of health care delivery, practice and quality across the country. Its massive pool of national, regional, local and provider-level health care utilization and cost data, derived from the Medicare database, has documented striking geographical variations in the delivery of health care services. But it has also changed our understanding of the efficiency and effectiveness of health care delivery and demonstrated that more medical care does not necessarily mean better care—that the wide disparities in health care spending and utilization do not track with measurable improvements in health care quality. In fact, higher utilization at the end of life may represent both harm to patients and billions of dollars in wasteful and unnecessary health care spending.

The Dartmouth Atlas Project, founded by Dr. John E. Wennberg, is based in the Dartmouth Institute for Health Policy and Clinical Practice at Dartmouth University. Its databases are used by health care policy-makers, analysts, health care executives, researchers, and, increasingly, palliative care advocates seeking to plan or justify the need for palliative care services to help their hospitals better manage these high-need, high-cost, high-utilization patients.
“Concern about overly aggressive care for patients at the end of life has sparked increased interest both in palliative care and in aligning the kinds of services provided to dying patients with their well-informed preferences,” the report states. “Patient wishes may have less influence on intensity of care than the practice patterns of the hospital where the care is given.”

Taken together, these figures start to sketch a picture of how much potentially futile or ineffective care a hospital or a region provides to patients during their final months of life or during the hospitalization in which death occurs—as well as creating an opportunity to compare performance on these variables among peers.

Our analyses show there is great variation in end-of-life care across regions and states. Digging deeper, our research group has identified that those hospitals with high performance scores (100 or above) have adopted advanced palliative care organizational (APCO) principles in which there are what we refer to as “learning communities”. This learning community is essentially a group of palliative care stakeholders who "join" together and are driven by a desire to share problems, knowledge, experiences, insights, templates, tools, and best practices around palliative care.

I'm interested to hear from those involved in learning communities sponsored by APCOs.