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Is survival better at hospitals with higher "end-of-life" treatment intensity?

ABSTRACT: Concern regarding wide variations in spending and intensive care unit use for patients at the end of life hinges on the assumption that such treatment offers little or no survival benefit.To explore the relationship between hospital "end-of-life" (EOL) treatment intensity and postadmission survival.Retrospective cohort analysis of Pennsylvania Health Care Cost Containment Council discharge data April 2001 to March 2005 linked to vital statistics data through September 2005 using hospital-level correlation, admission-level marginal structural logistic regression, and pooled logistic regression to approximate a Cox survival model.A total of 1,021,909 patients > or =65 years old, incurring 2,216,815 admissions in 169 Pennsylvania acute care hospitals.EOL treatment intensity (a summed index of standardized intensive care unit and life-sustaining treatment use among patients with a high predicted probability of dying [PPD] at admission) and 30- and 180-day postadmission mortality.There was a nonlinear negative relationship between hospital EOL treatment intensity and 30-day mortality among all admissions, although patients with higher PPD derived the greatest benefit. Compared with admission at an average intensity hospital, admission to a hospital 1 standard deviation below versus 1 standard deviation above average intensity resulted in an adjusted odds ratio of mortality for admissions at low PPD of 1.06 (1.04-1.08) versus 0.97 (0.96-0.99); average PPD: 1.06 (1.04-1.09) versus 0.97 (0.96-0.99); and high PPD: 1.09 (1.07-1.11) versus 0.97 (0.95-0.99), respectively. By 180 days, the benefits to intensity attenuated (low PPD: 1.03 [1.01-1.04] vs. 1.00 [0.98-1.01]; average PPD: 1.03 [1.02-1.05] vs. 1.00 [0.98-1.01]; and high PPD: 1.06 [1.04-1.09] vs. 1.00 [0.98-1.02]), respectively.Admission to higher EOL treatment intensity hospitals is associated with small gains in postadmission survival. The marginal returns to intensity diminish for admission to hospitals above average EOL treatment intensity and wane with time.

SUBMITTER: Barnato AE

PROVIDER: S-EPMC3769939 | biostudies-literature | 2010 Feb

REPOSITORIES: biostudies-literature

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Is survival better at hospitals with higher "end-of-life" treatment intensity?

Barnato Amber E AE Chang Chung-Chou H CC Farrell Max H MH Lave Judith R JR Roberts Mark S MS Angus Derek C DC

Medical care 20100201 2

<h4>Background</h4>Concern regarding wide variations in spending and intensive care unit use for patients at the end of life hinges on the assumption that such treatment offers little or no survival benefit.<h4>Objective</h4>To explore the relationship between hospital "end-of-life" (EOL) treatment intensity and postadmission survival.<h4>Research design</h4>Retrospective cohort analysis of Pennsylvania Health Care Cost Containment Council discharge data April 2001 to March 2005 linked to vital ...[more]

PMID: 20057328

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Project description:Hospitals vary substantially in their end-of-life (EOL) treatment intensity. It is unknown if patterns of EOL treatment intensity are consistent across conditions.To explore the relationship between hospitals' cancer- and non-cancer-specific EOL treatment intensity.We conducted a retrospective cohort analysis of Pennsylvania acute care hospital admissions for either cancer or congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD) between 2001 and 2007, linked to vital statistics through 2008. We calculated Bayes's shrunken case-mix standardized (observed-to-expected) ratios of intensive care and life-sustaining treatment use among two EOL cohorts: those prospectively identified at high probability of dying on admission and those retrospectively identified as terminal admissions (decedents). We then summed these to create a hospital-specific prospective and retrospective overall EOL treatment intensity index for cancer vs. CHF/COPD.The sample included 207,523 admissions with 15% or greater predicted probability of dying on admission among 172,041 unique adults and 120,372 terminal admissions at 166 hospitals; these two cohorts overlapped by 52,986 admissions. There was substantial variation between hospitals in their standardized EOL treatment intensity ratios among cancer and CHF/COPD admissions. Within hospitals, cancer- and CHF/COPD-specific standardized EOL treatment intensity ratios were highly correlated for intensive care unit (ICU) admission (prospective ? = 0.81; retrospective ? = 0.78), ICU lengths of stay (? = 0.76; 0.64), mechanical ventilation (? = 0.73; 0.73), and hemodialysis (? = 0.60; 0.71) and less highly correlated for tracheostomy (? = 0.43; 0.53) and gastrostomy (? = 0.29; 0.30). Hospitals' overall EOL intensity index for cancer and CHF admissions were correlated (prospective ? = 0.75; retrospective ? = 0.75) and had equal group means (P-value = 0.631; 0.699).Despite substantial difference between hospitals in EOL treatment intensity, within-hospital homogeneity in EOL treatment intensity for cancer- and non-cancer populations suggests the existence of condition-insensitive institutional norms of EOL treatment.

Project description:To examine inpatient intensive care unit (ICU) and intensive procedure use by race among Medicare decedents, using utilization among survivors for comparison.Retrospective observational analysis of inpatient claims using multivariable hierarchical logistic regression.United States, 1989-1999.Hospitalized Medicare fee-for-service decedents (n = 976,220) and survivors (n = 845,306) aged 65 years or older.Admission to the ICU and use of one or more intensive procedures over 12 months, and, for inpatient decedents, during the terminal admission. Black decedents with one or more hospitalization in the last 12 months of life were slightly more likely than non-blacks to be admitted to the ICU during the last 12 months (49.3% vs. 47.4%, p <.0001) and the terminal hospitalization (41.9% vs. 40.6%, p < 0.0001), but these differences disappeared or attenuated in multivariable hierarchical logistic regressions (last 12 months adjusted odds ratio (AOR) 1.0 [0.99-1.03], p = .36; terminal hospitalization AOR 1.03 [1.0-1.06], p = .01). Black decedents were more likely to undergo an intensive procedure during the last 12 months (49.6% vs. 42.8%, p < .0001) and the terminal hospitalization (37.7% vs, 31.1%, p < .0001), a difference that persisted with adjustment (last 12 months AOR 1.1 [1.08-1.14], p < .0001; terminal hospitalization AOR 1.23 [1.20-1.26], p < .0001). Patterns of differences in inpatient treatment intensity by race were reversed among survivors: blacks had lower rates of ICU admission (31.2% vs. 32.4%, p < .0001; AOR 0.93 [0.91-0.95], p < .0001) and intensive procedure use (36.6% vs. 44.2%; AOR 0.72 [0.70-0.73], p <.0001). These differences were driven by greater use by blacks of life-sustaining treatments that predominate among decedents but lesser use of cardiovascular and orthopedic procedures that predominate among survivors. A hospital's black census was a strong predictor of inpatient end-of-life treatment intensity.Black decedents were treated more intensively during hospitalization than non-black decedents, whereas black survivors were treated less intensively. These differences are strongly associated with a hospital's black census. The causes and consequences of these hospital-level differences in intensity deserve further study.

Project description:ObjectiveBlack patients are more likely than white patients to die in the hospital with intensive care and life-sustaining treatments and less likely to use hospice. Regional concentration of high end-of-life (EOL) treatment intensity practice patterns may disproportionately affect black patients. We calculated and compared race-specific hospital-level EOL treatment intensity in Pennsylvania.MethodsWe conducted a retrospective cohort analysis of Pennsylvania acute care hospital admissions, 2001-2007, among black and white admissions ≥21 years old at high probability of dying (HPD) (≥15% predicted probability of dying at admission). We calculated hospitals' race-specific observed, expected, and Bayes' shrunken observed-to-expected ratios of intensive care unit (ICU) admission, ICU length of stay (LOS), intubation/mechanical ventilation, hemodialysis, tracheostomy, and gastrostomy among HPD admissions; and an empirically weighted EOL treatment intensity index summing these ratios.ResultsThere were 35,609 black HPD admissions (27,576 unique patients) and 311,896 white HPD admissions (252,662 unique patients) to 182 hospitals. Among 95 hospitals with ≥30 black HPD admissions, 80% of black admissions were concentrated in 29 hospitals, where black-specific observed and expected EOL measures were usually higher than white-specific measures (p < 0.001 for all but 5/24 measures). Hospitals' black-specific and white-specific observed-to-expected ratios of ICU and life-sustaining treatment (LST) (rho 0.52-0.90) and EOL index (rho = 0.92) were highly correlated. However, black-specific observed-to-expected ratios and overall EOL intensity index were consistently lower than white-specific ratios (p < 0.001 for all except hemodialysis).ConclusionsIn Pennsylvania, black-serving hospitals have higher standardized EOL treatment intensity than nonblack-serving hospitals, contributing to black patients' relatively higher use of intensive treatment. However, conditional on being admitted to the same high-intensity hospital and after risk adjustment, blacks are less intensively treated than whites.

Project description:ImportanceAlthough hospice use is increasing and patients in the US are increasingly dying at home, racial disparities in treatment intensity at the end of life, including hospice use, remain.ObjectiveTo examine differences between Black and White patients in end-of-life care in a population sample with well-characterized causes of death.Design, setting, and participantsThis study used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, an ongoing population-based cohort study with enrollment between January 25, 2003, and October 3, 2007, with linkage to Medicare claims data. Multivariable logistic regression models were used to examine racial and regional differences in end-of-life outcomes and in stroke mortality among 1212 participants with fee-for-service Medicare who died between January 1, 2013, and December 31, 2015, owing to natural causes and excluding sudden death, with oversampling of Black individuals and residents of Southeastern states in the United States. Initial analyses were conducted in March 2019, and final primary analyses were conducted in February 2020.Main outcomes and measuresThe primary outcomes of interest were hospice use of 3 or more days in the last 6 months of life derived from Medicare claims files. Other outcomes included multiple hospitalizations, emergency department visits, and use of intensive procedures in the last 6 months of life. Cause of death was adjudicated by an expert panel of clinicians using death certificates, proxy interviews, autopsy reports, and medical records.ResultsThe sample consisted of 1212 participants (630 men [52.0%]; 378 Black individuals [31.2%]; mean [SD] age at death, 81.0 [8.6] years) of 2542 total deaths. Black decedents were less likely than White decedents to use hospice for 3 or more days (132 of 378 [34.9%] vs 385 of 834 [46.2%]; P < .001). After stratification by cause of death, substantial racial differences in treatment intensity and service use were found among persons who died of cardiovascular disease but not among patients who died of cancer. In analyses adjusted for cause of death (dementia, cancer, cardiovascular disease, and other) and clinical and demographic variables, Black decedents were significantly less likely to use 3 or more days of hospice (odds ratio [OR], 0.72; 95% CI, 0.54-0.96) and were more likely to have multiple emergency department visits (OR, 1.35; 95% CI, 1.01-1.80) and hospitalizations (OR, 1.39; 95% CI, 1.02-1.89) and undergo intensive treatment (OR, 1.94; 95% CI, 1.40-2.70) in the last 6 months of life compared with White decedents.Conclusions and relevanceDespite the increase in the use of hospice care in recent decades, racial disparities in the use of hospice remain, especially for noncancer deaths. More research is required to better understand racial disparities in access to and quality of end-of-life care.

Project description:BACKGROUND: In primary esophageal cancer, studies have frequently focused on surgical patients in an effort to link outcome to hospital- or surgeon-related experience, with operative mortality used as the main outcome measure. Many studies have found an inverse relationship between operative mortality and hospital volume and surgical expertise. This study aims to assess the influence of surgeon-related expertise and hospital volume on the relative survival of operated esophageal cancer patients. METHODS: From January 1994 to January 2002, a total of 1149 consecutive patients with primary esophageal cancer were diagnosed in the region of the Comprehensive Cancer Center North-Netherlands. As a proxy for surgeon-related expertise, hospitals in this region were categorized into three types: university, teaching nonuniversity, and nonteaching hospitals. The influence of hospital type on the relative survival of operated patients was studied by a multivariate Poisson regression model. RESULTS: Of the 1149 patients, 18.5% underwent surgery. There was no evidence of selective referral for surgery between the three hospital types with regard to age, tumor stage, and location. For operated patients, the 5-year relative survival was 49.2% for the university hospital versus 32.6% and 27.3% for teaching nonuniversity and nonteaching hospitals, respectively (P = .0039). When adjusted for age, tumor stage, hospital volume and referral frequency, the relative excess risk of death for the university hospital was considerably lower at .57 (95% confidence interval, .29-1.12) compared with nonteaching hospitals and .43 (95% confidence interval, .24-.76) compared with teaching nonuniversity hospitals (P = .0126). CONCLUSIONS: In our region, patients with esophageal cancer who underwent esophagectomy in the university hospital had a markedly better relative survival compared with those who underwent surgery at teaching nonuniversity and nonteaching hospitals, emphasizing the need for referral of esophageal surgery to centers with a greater experience.

Project description:BackgroundChildren with life-threatening conditions frequently experience high intensity care at the end of life, though most of this research only focused on children with cancer. Some research suggests inequities in care provided based on age, disease type, socioeconomic status, and distance that the child lives from a tertiary hospital. We examined: 1) the prevalence of indicators of high intensity end-of-life care (e.g., hospital stays, intensive care unit [ICU] stays, death in ICU, use of cardiopulmonary resuscitation [CPR], use of mechanical ventilation) and 2) the association between demographic and diagnostic factors and each indicator for children with any life-threatening condition in Canada.MethodsWe conducted a population-based retrospective cohort study using linked health administrative data to examine care provided in the last 14, 30, and 90 days of life to children who died between 3 months and 19 years of age from January 1, 2008 to December 31, 2014 from any underlying life-threatening medical condition. Logistic regression was used to model the association between demographic and diagnostic variables and each indicator of high intensity end-of-life care except number of hospital days where negative binomial regression was used.ResultsAcross 2435 child decedents, the most common diagnoses included neurology (51.1%), oncology (38.0%), and congenital illness (35.9%), with 50.9% of children having diagnoses in three or more categories. In the last 30 days of life, 42.5% (n = 1035) of the children had an ICU stay and 36.1% (n = 880) died in ICU. Children with cancer had lower odds of an ICU stay (OR = 0.47; 95% CI = 0.36-0.62) and ICU death (OR = 0.37; 95%CI = 0.28-0.50) than children with any other diagnoses. Children with 3 or more diagnoses (vs. 1 diagnosis) had higher odds of > 1 hospital stay in the last 30 days of life (OR = 2.08; 95%CI = 1.29-3.35). Living > 400 km (vs < 50 km) from a tertiary pediatric hospital was associated with higher odds of multiple hospitalizations (OR = 2.09; 95%CI = 1.33-3.33).ConclusionHigh intensity end of life care is prevalent in children who die from life threatening conditions, particularly those with a non-cancer diagnosis. Further research is needed to understand and identify opportunities to enhance care across disease groups.

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Is survival better at hospitals with higher "end-of-life" treatment intensity?

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Is survival better at hospitals with higher "end-of-life" treatment intensity?

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