Great Variation in End-of-Life Care

Even the best hospitals differ sharply, study finds

THURSDAY, March 11, 2004 (HealthDayNews) -- There are great differences in the way that even the best hospitals in the United States treat people nearing the end of life, says a study that can help such patients choose a center that is more likely to meet their individual needs.

The report is the latest in a long series done by Dr. John E. Wennberg and his colleagues at the Dartmouth Medical School Center for the Evaluative Clinical Sciences about the care offered by American hospitals.

"In this study, they looked at a very select group of hospitals, those in academic medical centers, in a very, very controlled way," says Megan McAndrew Cooper, editor of the Dartmouth Atlas of Health Care, in which the center's data are published. "They came down to just 77 hospitals."

"Extensive variation in each measure existed among the 77 hospital cohorts," says a report on the study in the British Medical Journal. The hospitals were chosen from the 2001 "best hospital" list published by U.S. News and World Report.

Each of those measures can play a major role in the feelings and physical well-being of patients in the last six months of life, who were the focus of the study. They include the number of days spent in the hospital rather than at home, number of hospital days in intensive care units, number of physician visits, percentage of patients seeing 10 or more doctors, and the percentage of patients who died in the hospital rather than at home.

The differences are impressive. Days spent in the hospital ranged from a low of 9.4 to a high of 27.1. Days spent in the ICU ranged from 1.6 to 9.5. The number of physician visits was as low as 17.6 to 76.2. And the percentage of patients who died in the hospital was as low as 15.9 and as high as 55.6.

People can use this information, which will be available first on the British Medical Journal Web site and later on the Dartmouth Web site to make a hospital-by-hospital comparison, Cooper says.

"For example, if you are in New York and would rather not be admitted to intensive care, you would be better off being admitted to Mount Sinai Hospital than New York Medical Center," she says.

The Dartmouth researchers plan to gather similar data on many more hospitals, and will post it as it becomes available, Cooper says.

The American Hospital Association welcomes the study, says Rick Wade, senior vice president of the association, which has published similar studies by the Dartmouth group.

"The studies are very provocative," Wade says. "They raise lots of questions about the incentives in our medical care system. In general, the more you do, the more they pay you."

For hospitals, Wade says, the lesson of the Dartmouth research is that there is a need "for having greater standardization in the way physicians practice medicine. We need more protocols and a stronger set of protocols, hospital by hospital."

The lesson for patients is the need for advance directives and living wills, documents that "make very clear to the doctor what your value system dictates in terms of care," Wade says.

But Cooper says studies have found that such documents and patients' expressed wishes have relatively little effect on care. Even when patients were given nurse coaches to help them express their wishes, "that had no effect at all," she says.

And so it is important for a potential patient to be aware of how medicine is practiced in a specific hospital, even those that rank the highest, Cooper says.

"What we are challenging is the notion that if you go to a big-city medical center, they know what they are doing and do it better," she says

More information

Get hospital data at the Dartmouth Atlas of Health Care or the American Hospital Association.

SOURCES: Megan McAndrew Cooper, editor, Dartmouth Atlas of Health Care, Hanover, N.H.; Rick Wade, senior vice president, American Hospital Association, Washington, D.C.; March 13, 2004, British Medical Journal
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