Objective-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.Research Design-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.Results-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).Conclusions-Medicare beneficiaries generally prefer treatment focused on palliation rather than life-extension. Differences in preferences are unlikely to explain regional variations in EOL spending. Previous studies have shown that regions with greater overall EOL spending do not have better outcomes; mortality, quality of care, and patient satisfaction among cohorts of patients with common serious conditions are sometimes worse, 2,3 as are perceptions of the quality of EOL care among bereaved family members. 4 In contrast, higher spending regions do have a greater regional supply of specialists, 5 hospital and ICU beds, 6-9 and other technologies. 10,11 Physicians who practice in high-intensity regions have a greater tendency to recommend tests, referrals, and treatments for patients described in structured vignettes and are less likely to refer to hospice. 12,13 It is unknown whether these differences in supply and physician practice style reflect differences in preferences for treatment among patients who reside in these highspending regions. Yet, the policy prescriptions for addressing these regional variations depend critically on whether they are the consequence of differences across regions in patient preferences, the consequence of physician "enthusiasm" or "supplier-induced demand," or other factors related to the supply of health care capacity. 14-16We sought to determine whether EOL tr...
BACKGROUND: Studies using local samples suggest that racial minorities anticipate a greater preference for lifesustaining treatment when faced with a terminal illness. These studies are limited by size, representation, and insufficient exploration of sociocultural covariables.
Efforts to improve the quality and costs of U.S. health care have focused largely on fostering physician adherence to evidence-based guidelines, ignoring the role of clinical judgment in more discretionary settings. We surveyed primary care physicians to assess variability in discretionary decision making and evaluate its relationship to the cost of health care. Physicians in high-spending regions see patients back more frequently and are more likely to recommend screening tests of unproven benefit and discretionary interventions compared with physicians in low-spending regions; however, both appear equally likely to recommend guideline-supported interventions. Greater attention should be paid to the local factors that influence physicians' clinical judgment in discretionary settings.
CMS uses Adult HCAHPS® scores for public reporting and pay-for-performance for most U.S. hospitals, but no publicly available standardized survey of inpatient experience of care exists for pediatrics. To fill the gap, CMS/AHRQ commissioned the development of the Consumer Assessment of Healthcare Providers and Systems Hospital Survey – Child Version (Child HCAHPS), a survey of parents/guardians of pediatric patients (<18 years old) who were recently hospitalized. This Special Article describes the development of Child HCAHPS, which included an extensive review of the literature and quality measures, expert interviews, focus groups, cognitive testing, pilot testing of the draft survey, a national field test with 69 hospitals in 34 states, psychometric analysis, and end-user testing of the final survey. We conducted extensive validity and reliability testing to determine which items would be included in the final survey instrument and to develop composite measures. We analyzed national field test data from 17,727 surveys collected from 11/12-1/14 from parents of recently hospitalized children. The final Child HCAHPS instrument has 62 items, including 39 patient experience items, 10 screeners, 12 demographic/descriptive items, and 1 open-ended item. The 39 experience items are categorized based on testing into 18 composite and single-item measures. Our composite and single-item measures demonstrated good to excellent hospital-level reliability at 300 responses per hospital. Child HCAHPS was developed to be a publicly available standardized survey of pediatric inpatient experience of care. It can be used to benchmark pediatric inpatient experience across hospitals and assist in efforts to improve the quality of inpatient care.
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