Home > End of life care, Health care > Is end-of-life care getting better and worse?

Is end-of-life care getting better and worse?

Medicare patients who have severe chronic diseases are becoming less likely to die in a hospital and more likely to receive hospice care, according to a new report from the Dartmouth Atlas of Health Care. This indicates that patients’ preferences for treatment are being honored more frequently — but there are also contradictory findings.

The number of seriously ill patients who see 10 or more doctors during their last six months of life is also increasing, as is the use of specialist MDs, the Dartmouth researchers found. These trends drive up spending, while use of hospice drives costs down.

Data show the same patterns for the Rochester, NY, area (where I live) as for the U.S. as a whole. So the Beatles may be partly right: it could be getting better…and worse…all the time.

To establish trends and identify variation in EOL care, the Dartmouth folks examined data for the years 2003 to 2007, studying Medicare beneficiaries who died, who were hospitalized for non-surgical treatment at least once in their last two years, and who had one or more of nine chronic diseases.

The researchers were following the money:

“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, MS, co-principal investigator for the Dartmouth Atlas project.

Here are some key findings, comparing data from 2003 and 2007 for Rochester, NY State, and the US:

Rochester New York USA
Deaths in hospitals 31.3% / 26% 40.8% / 37.5% 32.2% / 28.1%
Hospital days last 6 mos of life 12.2 / 11.2 16.2 / 15.9 11.3 / 10.9
Hospice days per decedent 9.6 / 13.4 7.4 / 10 12.4 / 18.3
Patients seeing 10+ Mds 20.1% / 27.3% 40.4% / 45.7% 30.8% / 36.1%
Specialist MD inputs 4.9 / 5.1

As in previous Dartmouth Atlas studies, this one found widespread variation in patterns of medical care from region to region. For example, the NY State results are driven by very high rates of hospitalization and very low rates of hospice use in NY City and adjacent suburbs, while Rochester falls much closer to the national median.

Throughout this period, the constant was the importance of geography; the care patients received in the months before they died depended largely on where they lived and received their care.

The question remains: to what extent does supply (of hospital beds, of specialist MDs) drive demand, and to what extent do the data on EOL care reflect what seriously ill patients and their families actually want? If fewer patients are dying in hospitals and more are choosing hospice care, it “may also be evidence of attempts to provide care that aligns more closely with patient preferences,” the report says.

But what about increased use of MD labor, especially specialist MDs? Is that being driven by system bias or patient wishes? The data alone can’t tell us.

“While current trends demonstrate the change is occurring in many regions and at many institutions, it is not always in the direction that patients may prefer,” says Dartmouth Atlas honcho Elliott S. Fisher, MD, MPH. “Much work remains to ensure that future variation in care reflects the well-informed preferences of patients.”

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