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J Pain Symptom Manage. 2015 Mar;49(3):521-9.e1-5. doi: 10.1016/j.jpainsymman.2014.06.017. Epub 2014 Aug 15.

Hospital end-of-life treatment intensity among cancer and non-cancer cohorts.

Author information

1
Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Department of Health Care Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA. Electronic address: barnae@upmc.edu.
2
Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
3
Children's Hospital of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
4
Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA.

Abstract

CONTEXT:

Hospitals vary substantially in their end-of-life (EOL) treatment intensity. It is unknown if patterns of EOL treatment intensity are consistent across conditions.

OBJECTIVES:

To explore the relationship between hospitals' cancer- and non-cancer-specific EOL treatment intensity.

METHODS:

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.

RESULTS:

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 ρ = 0.81; retrospective ρ = 0.78), ICU lengths of stay (ρ = 0.76; 0.64), mechanical ventilation (ρ = 0.73; 0.73), and hemodialysis (ρ = 0.60; 0.71) and less highly correlated for tracheostomy (ρ = 0.43; 0.53) and gastrostomy (ρ = 0.29; 0.30). Hospitals' overall EOL intensity index for cancer and CHF admissions were correlated (prospective ρ = 0.75; retrospective ρ = 0.75) and had equal group means (P-value = 0.631; 0.699).

CONCLUSION:

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.

KEYWORDS:

Terminal care; cancer; chronic obstructive pulmonary disease; congestive heart failure; end-of-life care; health services; hospital; intensive care; mechanical ventilation; utilization; variation

PMID:
25135656
PMCID:
PMC4329285
DOI:
10.1016/j.jpainsymman.2014.06.017
[Indexed for MEDLINE]
Free PMC Article
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