Approximately 29% of Medicare patients with cancer died in a hospital, and hospice care was inconsistent among medical centers in the United States, according to a report published Nov. 16 by the Dartmouth Institute for Health Policy & Clinical Practice.
The rate of hospital deaths varied widely by region, ranging from 47% in Manhattan (New York City) to 7% in Mason City, Iowa.
"The bottom line is that the care patients receive has less to do with what they want and more to do with the hospital they seek care from," Dr. David Goodman of Dartmouth University, Hanover, N.H., said in a press briefing. "We as physicians often make assumptions about what patients and families want for their lives. What patients really want is for a physician to be honest with them and to share the full range of options with them."
The report, "Quality of End-of-Life Cancer Care for Medicare Beneficiaries: Regional and Hospital-Specific Analyses," is the first to focus on cancer care at the end of life for the Medicare population in particular. The report was produced by the Dartmouth Atlas Project, which has been documenting the use of medical resources in the United States for more than 2 decades.
Researchers reviewed data from 235,821 Medicare patients (aged 65 years and older) with metastatic or aggressive cancer who died in 2003-2007. They identified regional trends as well as information about specific academic medical centers.
Nationwide, approximately 61% of cancer patients were hospitalized at least once during their last month of life. Hospital admissions varied from approximately 70% of cancer patients in Detroit to 46% of cancer patients in San Angelo, Tex.
The researchers identified the highest rates of hospitalization during the last month of life (more than 75%) among cancer patients at two hospitals in Detroit: St. John Hospital and Medical Center and Sinai-Grace Hospital. The lowest rate of hospitalization during the last month of life was 45% of cancer patients at the University of Washington Medical Center in Seattle.
Chemotherapy was part of care during the last 2 weeks of life in approximately 6% of patients nationwide, but the rate exceeded 10% in eight areas, including Olympia, Wash. (12%), and San Antonio (11%).
The researchers also found that fewer than 50% of cancer patients with a poor prognosis received hospice care, and some centers provided hospice care only in the last few days of life.
The degree of variation in the findings is too great to be explained by racial or ethnic preferences for aggressive end-of-life care, and adjustment for socioeconomic status does not change the results, said Dr. Goodman said.
But the data show that investment in beds, ICU facilities, and palliative care services is quite different from one health care system to another, he said.
The report highlights the need for doctors and health systems "to take a look at themselves and examine where they need to make their investments," said Dr. Goodman, who added that clinicians "need to look at ourselves in terms of how we communicate with patients" about cancer care options.
In a commentary accompanying the report, Dr. Joan Teno of Brown University in Providence, R.I., emphasized the need for health care providers to educate patients about their prognoses and to provide hospice options.
"If opportunities to improve are identified, hospitals should work with the local hospice or existing palliative care consult service, and/or start a palliative care consult service," to ensure that the institution is delivering high-quality care, Dr. Teno wrote.
Conversations about end-of-life care need to be started early in the course of treatment, Dr. Goodman said. "Our preferences can certainly change, but opening up the conversation early allows the conversation to evolve over time. The tragedy is when those conversations start near the end."
In a statement, Dr. George W. Sledge Jr., president of the American Society of Clinical Oncology said, "While saving lives is the oncologist’s goal, helping individuals live their final days in comfort and dignity is one of the most valuable and important responsibilities of our profession.
"Options to enhance a patient’s quality of life should be discussed throughout the course of their treatment. It is critical that we increase medical training in end-of-life patient communication and planning, and that Medicare and other insurers cover the costs of these essential conversations," Dr. Sledge noted.
The study was supported in part by the Robert Wood Johnson Foundation.