Improving Performance in Late-Life Care - A Modest Effort Starts in Philadelphia

I’m working with a small group of Philadelphia-area  hospital executives who have joined together in a campaign to improve late-life care in the region. While recognizing that many factors influence the overall performance of communities in how patients are treated in the final stage of life, these executives appreciate the enormous sphere of influence their institutions exert on their respective communities.

Until shown the DAI Palliative Performance Reports for their respective hospitals, these executives, all of whose hospitals reportedly have a palliative care service, felt  their institutions had been effectively caring for the late-life needs of their patients. Yet the hospitals’ performance lagged behind state and national benchmarks, and well behind the performance of  hospital exemplars.  The Philadelphia region’s performance similarly lagged.

Examples abound.  According to the DAI Palliative Performance Profile (P3) for Philadelphia, a Philadelphia resident will spend 20% more days in a hospital during last six months of life than the national average, and twice as many days as would a resident of the exemplar region of Portland, Oregon. The Philadelphia resident is one-third more likely to die in a hospital than his counterpart in Portland, and twice as likely to have had an ICU stay associated with that terminal hospitalization.  On a positive note, at least one indicator shows Philadelphia to be performing better than national benchmarks – while 41.9% of those who die in the US use the hospice benefit, 44.6% of Philadelphia residents received services from a licensed hospices prior to their death. Yet considerable opportunity  remains for improvement.
How much? Consider that in 10% of communities  across the nation (the exemplar benchmark)  more than 55% of their decedents utilized the hospice benefit.

While few of the executives were surprised by Philadelphia’s poor performance in late-life care, most were surprised by the enormous gaps between the region’s performance and that of exemplar communities. Yet, should we be so surprised? After all, the Dartmouth Medical Atlas (from which the DAI P3 draws its data) has for years documented such variations. In a recent study titled Trends and Variation in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness, the authors concluded that  geography continues to play a huge role in late-life care, noting that “care patients received in the months before they died depended largely on where they lived, and widespread variations persist.”

In future posts, we’ll take a closer look at what the DAI Palliative Performance Profiles tell us, and perhaps more importantly, how they might provide sharper focus for performance improvement campaigns, not unlike the modest effort  briefly described above. In the meantime, I invite your comments on the state of late-life care in your region, or the US, in general, and welcome your ideas on the sort of performance improvement campaigns which could make a difference. We’ll also take a closer look at exemplar communities (read here for an earlier blog post on this subject) and how do they do that?