Hospital End-of-Life Treatment Intensity Among Cancer and Non-Cancer Cohorts

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. Objective 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 2001–2007, linked to vital statistics through 2008. We calculated Bayes’ 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 (HPD) upon 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 versus CHF/COPD. Results The sample included 207,523 admissions with 15% or greater predicted probability of dying upon admission among 172,041 adults and 120,372 terminal admissions at 166 hospitals; these 2 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 ICU admission (‘prospective’ ρ=.81; ‘retrospective’ ρ=.78), ICU length of stay (ρ=.76; .64), mechanical ventilation (ρ=.73; .73), and hemodialysis (ρ=.60; .71), and less highly correlated for tracheostomy (ρ=.43; .53), and gastrostomy (ρ=.29; .30). Hospitals’ overall EOL intensity index for cancer and CHF/admissions were correlated (ρ=.75; ρ=.75) and had equal group means (p=.631; .699). Conclusions 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.

End‐of‐life care in an Australian acute hospital: a retrospective observational study

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Life-Sustaining Procedures, Palliative Care, and Cost Trends in Dying COPD Patients in U.S. Hospitals: 2005~2014

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Quality of End-of-Life Care Provided to Patients With Different Serious Illnesses

“…4,5 Researchers have found differences in care between certain diagnoses–-such as higher rates of mechanical ventilation among patients with chronic obstructive pulmonary disease (COPD) compared to cancer patients 5 —but much is still unknown. Moreover, previous work has typically been limited to administrative or chart review data, 4–7 which do not include patient or family perspectives. To address these important questions, we compare quality of care for decedents across multiple diagnoses, the first study to do so, to our knowledge.…”