A recent post on this blog (read here) commented on the Dartmouth Atlas Project findings of variation in late-life care for advanced cancer patients. While the findings of variation are not surprising to those who have been following the Project's studies over the past two decades, what did leave me open-mouthed was the enormity of these variations. In some communities, more than 70% of patients with advanced cancer did NOT receive hospice care, staggering even when one considers that nationally 45% did not receive hospice care. If hospice care is not provided to nearly half of patients with advanced cancer, what must those figures be for patients with other advanced illnesses for which prognostication is more difficult. Conversely, in some communities, more than 70% of patients with advanced cancer DID receive hospice care.
I'm encouraged, nonetheless, by the widespread attention given to this study, in both national and regional publications. It's almost as if these study findings have sounded an alert, one that says WE CAN DO BETTER. Much better.
The Los Angeles Times commented that "the study found that patients in Minneapolis were four times less likely than those in Los Angeles to receive aggressive life-sustaining treatment during their last weeks on earth." The article went on to bluntly say "In other words, unless people strongly assert their preferences, their end-of-life care will largely be determined by the prevailing customs of their communities."
An article in the Chicago Tribune commented, "the gap was even greater for frail, seriously ill cancer patients who received CPR, mechanical ventilation and feeding tubes — interventions deemed of little value as the end of life approaches. Some 16 percent of these patients got these therapies in Chicago, compared with 9 percent across the U.S." More from the Tribune, "that analysis reveals some stark differences among Illinois hospitals. Notably, for Evanston Hospital, Glenbrook Hospital and Highland Park Hospital — all part of NorthShore University HealthSystem — only 19 percent of Medicare patients with advanced cancer died in the hospital, compared with 38 percent at Northwestern Memorial Hospital."
The Milwaukee Journal-Sentinel headline read bluntly that late-life care "needs improving". It offered the following example of variations within the state: "At Columbia St. Mary's two hospitals in Milwaukee, which have since been consolidated, 11.2% of patients with advanced cancer died in the hospital. At St. Mary's Hospital in Madison, it was 16%. In contrast, an average of 37.3% of patients with advanced cancer at Wheaton Franciscan Healthcare-St. Joseph Campus died in the hospital, although this may be because the hospital has an area designed for patients near the end of life who want to be in a residential setting." Perhaps.
Not all of the local news reports focused on laggards. The St. Petersburg Times found that study results in that community were generally better than national averages. And the Globe Gazette (Iowa) highlighted the exemplary performance of Mason City, Iowa in most indicators.
Future posts will take closer looks at communities and hospitals with exemplary performance in an effort to answer the question: How Did they Do That? In the meantime, I invite your thoughts.
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