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      End-Of-Life Care For Medicare Beneficiaries With Cancer Is Highly Intensive Overall And Varies Widely

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          Abstract

          Studies have shown that cancer care near the end of life is more aggressive than many patients prefer. Using a cohort of deceased Medicare beneficiaries with poor-prognosis cancer, meaning that they were likely to die within a year, we examined the association between hospital characteristics and eleven end-of-life care measures, such as hospice use and hospitalization. Our study revealed a relatively high intensity of care in the last weeks of life. At the same time, there was more than a twofold variation within hospital groups with common features, such as cancer center designation and for-profit status. We found that these hospital characteristics explained little of the observed variation in intensity of end-of-life cancer care and that none reliably predicted a specific pattern of care. These findings raise questions about what factors may be contributing to this variation. They also suggest that best practices in end-of-life cancer care can be found in many settings and that efforts to improve the quality of end-of-life care should include every hospital category.

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          Most cited references22

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          Health care costs in the last week of life: associations with end-of-life conversations.

          Life-sustaining medical care of patients with advanced cancer at the end of life (EOL) is costly. Patient-physician discussions about EOL wishes are associated with lower rates of intensive interventions. Funded by the National Institute of Mental Health and the National Cancer Institute, Coping With Cancer is a longitudinal multi-institutional study of 627 patients with advanced cancer. Patients were interviewed at baseline and were followed up through death. Costs for intensive care unit and hospital stays, hospice care, and life-sustaining procedures (eg, mechanical ventilator use and resuscitation) received in the last week of life were aggregated. Generalized linear models were applied to test for cost differences in EOL care. Propensity score matching was used to reduce selection biases. Of 603 participants, 188 (31.2%) reported EOL discussions at baseline. After propensity score matching, the remaining 415 patients did not differ in sociodemographic characteristics, recruitment sites, illness acknowledgment, or treatment preferences. Further analyses, adjusted by quintiles of propensity scores and significant confounders, revealed that the mean (SE) aggregate costs of care (in 2008 US dollars) were $1876 ($177) for patients who reported EOL discussions compared with $2917 ($285) for patients who did not, a cost difference of $1041 (35.7% lower among patients who reported EOL discussions) (P =.002). Patients with higher costs had worse quality of death in their final week (Pearson production moment correlation partial r = -0.17, P =.006). Patients with advanced cancer who reported having EOL conversations with physicians had significantly lower health care costs in their final week of life. Higher costs were associated with worse quality of death.
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            Are regional variations in end-of-life care intensity explained by patient preferences?: A Study of the US Medicare Population.

            We sought to test whether variations across regions in end-of-life (EOL) treatment intensity are associated with regional differences in patient preferences for EOL care. Dual-language (English/Spanish) survey conducted March to October 2005, either by mail or computer-assisted telephone questionnaire, among a probability sample of 3480 Medicare part A and/or B eligible beneficiaries in the 20% denominator file, age 65 or older on July 1, 2003. Data collected included demographics, health status, and general preferences for medical care in the event the respondent had a serious illness and less than 1 year to live. EOL concerns and preferences were regressed on hospital referral region EOL spending, a validated measure of treatment intensity. A total of 2515 Medicare beneficiaries completed the survey (65% response rate). In analyses adjusted for age, sex, race/ethnicity, education, financial strain, and health status, there were no differences by spending in concern about getting too little treatment (39.6% in lowest spending quintile, Q1; 41.2% in highest, Q5; P value for trend, 0.637) or too much treatment (44.2% Q1, 45.1% Q5; P = 0.797) at the end of life, preference for spending their last days in a hospital (8.4% Q1, 8.5% Q5; P = 0.965), for potentially life-prolonging drugs that made them feel worse all the time (14.4% Q1, 16.5% Q5; P = 0.326), for palliative drugs, even if they might be life-shortening (77.7% Q1, 73.4% Q5; P = 0.138), for mechanical ventilation if it would extend their life by 1 month (21% Q1, 21.4% Q5; P = 0.870) or by 1 week (12.1% Q1, 11.7%; P = 0.875). Medicare beneficiaries generally prefer treatment focused on palliation rather than life-extension. Differences in preferences are unlikely to explain regional variations in EOL spending.
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              Evaluating claims-based indicators of the intensity of end-of-life cancer care.

              To evaluate measures that could use existing administrative data to assess the intensity of end-of-life cancer care. Benchmarking standards and statistical variation were evaluated using Medicare claims of 48,906 patients who died from cancer from 1991 through 1996 in 11 regions of the United States. We assessed accuracy by comparing administrative data to 150 medical records in one hospital and affiliated cancer treatment center. Systems not providing overly aggressive care near the end of life would be ones in which less than 10% of patients receive chemotherapy in the last 14 days of life, less than 2% start a new chemotherapy regimen in the last 30 days of life, less than 4% have multiple hospitalizations or emergency room visits or are admitted to the intensive care unit (ICU) in the last month of life, and less than 17% die in an acute care institution. At least 55% of patients would receive hospice services before death from cancer, and less than 8% of those would be admitted to hospice within only 3 days of death. All measures were found to have accuracy ranging from 85 to 97% and 2- to 5-fold adjusted variability between the 5th and 95th percentiles of performance. The usefulness of these measures will depend on whether the concept of intensity of care near death can be further validated as an acceptable and important quality issue among patients, their families, health care providers, and other stakeholders in oncology.
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                Author and article information

                Journal
                Health Affairs
                Health Affairs
                Health Affairs (Project Hope)
                0278-2715
                1544-5208
                April 2012
                April 2012
                : 31
                : 4
                : 786-796
                Affiliations
                [1 ] Nancy E. Morden ( ) is an assistant professor at the Dartmouth Medical School, a researcher at the Dartmouth Institute for Health Policy and Clinical Practice, and an investigator in the Cancer Control Research Program at the Dartmouth-Hitchcock Norris Cotton Cancer Center, in Lebanon, New Hampshire.
                [2 ] Chiang-Hua Chang is a research instructor at the Dartmouth Institute for Health Policy and Clinical Practice.
                [3 ] Joseph O. Jacobson is the chief quality officer at the Dana Farber Cancer Institute, in Boston, Massachusetts, and an associate clinical professor at Harvard Medical School.
                [4 ] Ethan M. Berke is an associate professor at Dartmouth Medical School, a researcher at the Dartmouth Institute for Health Policy and Clinical Practice, and an investigator in the Cancer Control Research Program at the Dartmouth-Hitchcock Norris Cotton Cancer Center.
                [5 ] Julie P.W. Bynum is an associate professor at the Dartmouth Institute for Health Policy and Clinical Practice and associate director of the institute’s Center for Health Policy Research.
                [6 ] Kimberly M. Murray is a research associate at the Maine Medical Center Research Institute’s Center for Outcomes Research and Evaluation, in Portland.
                [7 ] David C. Goodman is a professor of pediatrics and of health policy at Dartmouth Medical School and director of the Center for Health Policy Research at the Dartmouth Institute.
                Article
                10.1377/hlthaff.2011.0650
                22492896
                2fe147af-89e9-4076-aa94-0b86864e294f
                © 2012
                History

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