Wednesday, April 13, 2011

Variations in Late-Life Care Persist - What Can Be Done? And By Whom?

A recent blog post commented on the enormous clinical variation in late-life care. Another blog post remarked on the difficulty of "spreading the science of palliative care" because of the fragmented system delivering palliative care. And this week The Dartmouth Atlas Project  issued a study - "Trends and Variation in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness" - which further documented the enormous clinical variations across the nation as late-life (final six months) care is provided. The differences among communities is staggering, and these variations persist. For example, in 2007, chronically-ill patients in Manhattan spent, on average, 20.6 days in the hospital during their last six months of life, almost four times more than patients in Ogden, UT, where the average was 5.2 days. Chronically ill patients in Fort Lauderdale were half as likely to die in a hospital than similar patients in and around New York City. Is there a question as to which region's late-life care practices better comply with patient and family preferences?
The report documents trends from 2003 to 2007 in the use of medical resources to treat Medicare patients at the end of life at hospital referral regions and at 94 academic medical centers. The study found that Medicare patients diagnosed with severe chronic illness were less likely to die in a hospital and more likely to receive hospice care. They also had many more visits from physicians, particularly medical specialists, and spent more days in ICUs. The overall picture, one could say, is mixed; although patients experienced fewer hospital days and more hospice care, at the same time therre was an increase in the intensity of care for patients who were hospitalized.

"In addition to its effects on patients' quality of life, unnecessarily aggressive care carries a high
financial cost. About one-fourth of all Medicare spending goes to pay for the care of patients in their last year of life, and much of the growth in Medicare spending is the result of the high cost of treating chronic disease," said David C. Goodman, MD, lead author of the report, in a media release. Elliott S. Fisher, MD, report author and co-principal investigator of the Dartmouth Atlas Project, perhaps put it best, "While current trends demonstrate that change is occurring in many regions and at many institutions, it is not always in the direction that patients may prefer." Dr. Fisher went on to say more work needs to be done "to ensure that future variation in care reflects the well-informed preferences of patients."

Chronically ill patients were significantly more likely to be treated by 10 or more doctors in the last six months of life in 2007 than they were in 2003. Visiting such a number of physicians certainly must place a premium on effective care transitions. Is our current system well structured to enable effective and coordinated patient transitions?

Future posts on this blog will take a closer look at the findings of this Dartmouth study, and examine those regions, and academic medical centers, that may offer promising approaches. In other words, we'll identify exemplars.

We need to be better at disseminating the science and art of palliative care to reduce these clinical variations. But how to do that, and who should be leading the effort? Should we take a closer look at a national campaign to improve late-life care, like the 30/30/30 Campaign described in a previous post on this blog. Your thoughts are invited.


Ron Nielsen, MD said...

I think we need to rethink how we do CME. Palliative Care is one of those things you have to experience to understand. I don't think you can really get it just from a lecture. I think it would be good to actually "mix it up". That is, have every provider spend a week or two every couple of years in a practice setting that is markedly different from their own. For instance a physician at a university facility could spend a week with a rural provider and visa versa. Medicine isn't just matching a diagnosis to a treatment, it involves a whole system of care, and it is important for physicians to experience other systems.

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