Relationship between Staff Perceptions of Hospital Norms and Hospital-Level End-of-Life Treatment Intensity

Barnato, Amber E.; Bost, James E.; Farrell, Maxwell H.; Lave, Judith R.; Arnold, Robert M.; Rubio, Doris McGartland; Angus, Derek C.

doi:10.1089/jpm.2006.0258

Cited by 26 publications

(24 citation statements)

References 10 publications

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“…This finding is consistent with some prior research, 30,31 but our study extends current knowledge in 2 ways. First, prior studies have largely compared patterns of procedure use between FFS and capitated reimbursement systems, 19,32 rather than entirely distinct payment and care delivery systems such as VA and Medicare.…”

Section: Discussionsupporting

confidence: 94%

Variation in use of echocardiography among veterans who use the Veterans Health Administration vs Medicare

Kini

McCarthy

Rajaei

et al. 2015

American Heart Journal

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Background Rapid growth in the provision of cardiac imaging tests has led to concerns about overuse. Little is known about the degree to which health care delivery system characteristics influence use and variation in echocardiography. Methods We analyzed administrative claims of veterans with heart failure older than 65 years from 2007 to 2010 across 34 metropolitan service areas (MSAs). We compared overall rates and geographic variation in use of transthoracic echocardiography (TTE) between veterans who used the Veterans Health Administration (VA) and propensity-matched veterans who used Medicare. “Dual users” were excluded. Results There were no significant differences in clinical characteristics or mortality between the propensity-matched cohorts (overall n = 30,404 veterans, mean age 76 years, mortality rate 52%). The Medicare cohort had a significantly higher overall rate of TTE use compared with the VA cohort (1.25 vs 0.38 TTEs per person-year, incidence rate ratio 2.89 [95% CI 2.80-3.00], both P< .001), but a similar coefficient of variation across MSAs (0.36 [95% CI 0.27-045] vs 0.48 [95% CI 0.37-0.59]). There was a moderate to strong correlation in variation at the MSA level between cohorts (Spearman r = 0.58, P < .001). Conclusion Overall rates of TTE use were significantly higher in a Medicare cohort compared with a propensity score-matched VA cohort of veterans with heart failure living in urban areas, with similar relative degrees of geographic variation and moderate to strong regional correlation. Rates of TTE use may be strongly influenced by health care system characteristics, but local practice styles influence echocardiography rates irrespective of health system.

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Section: Discussionsupporting

confidence: 94%

Variation in use of echocardiography among veterans who use the Veterans Health Administration vs Medicare

Kini

McCarthy

Rajaei

et al. 2015

American Heart Journal

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“…5 Finally, other research suggests that the central drivers of practice variation are implicit professional norms or the local practice culture. 10;28 To understand each of these potential factors better, future research should explore the influences of physician supply, procedure capacity, social norms, practice culture, and appropriateness of procedure use.…”

Section: Discussionmentioning

confidence: 99%

“…6 In contrast, relatively little is known about variation in the rates of healthcare utilization among the 23% of Medicare beneficiaries who are covered under capitated plans via the Medicare Advantage (MA) program. 7 If the primary reason for geographic variation in healthcare utilization is varying financial incentives for physicians, one would expect that overall CV procedure rates and variation in procedure rates would be lower for MA patients than for MFFS patients.. On the other hand, if factors such as differences in patient clinical characteristics, 8;9 patient preferences for treatment, or local practice culture 10 are the central drivers of variation then one would expect that overall CV procedure rates and variation in procedure rates would be similar for MA patients than for MFFS patients.…”

Section: Introductionmentioning

confidence: 99%

Geographic Variation in Cardiovascular Procedure Use Among Medicare Fee-for-Service vs Medicare Advantage Beneficiaries

Matlock

Groeneveld

Sidney

et al. 2013

JAMA

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Context Little is known about how geographic variation of cardiovascular procedures compares between beneficiaries with Medicare Advantage (MA) and Medicare fee-for-service (MFFS). Objective To compare regional cardiovascular procedure rates between MFFS and MA beneficiaries. Design Cross-sectional study comparing rates of coronary angiography, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). Setting 32 Hospital Referral Regions (HRRs) in 12 states. Patients (or Participants) Medicare beneficiaries over age 65 between 2003–2007. Main Outcome Measure(s) Rates of coronary angiography, PCI and CABG. Results We evaluated a total of 878,339 MA patients and 5,013,650 MFFS patients across 32 HRRs. Compared with MFFS patients, MA patients had lower age-, sex-, race, and income-adjusted procedure rates for angiography (16.5/1000 person-years vs. 25.9/1000; p <0.001) and PCI (6.8/1000 vs. 9.8/1000; p<0.0001) but similar rates for CABG (3.1/1000 vs. 3.4/1000; p=0.33). Procedure rates varied widely among both MA and MFFS patients. For angiography, the rates ranged from 9.8/1000 to 40.6/1000 for MA beneficiaries and from 15.7/1000 to 44.3/1000 for MFFS beneficiaries. For PCI, the rates ranged from 3.5/1000 to 16.8/1000 for MA and from 4.7/1000 to 16.1/1000 for MFFS. The rates for CABG ranged from 1.5/1000 to 6.1/1000 for MA and from 2.5/1000 to 6.0/1000 for MFFS. Across regions, we found no statistically significant correlation between MA and MFFS beneficiary utilization for angiography (r = 0.19, p = 0.29) and modest correlations for PCI (r= 0.33, p = 0.06) and CABG (r = 0.35, p =0.05). Among MA beneficiaries, demographic(age, gender, race, and income) adjusted rates were highly correlated with demographic and disease adjusted rates ( r = 0.82 for angiography, 0.87 for PCI, and 0.97 for CABG; p<0.0001). Conclusions Rates of angiography and PCI, were significantly lower among MA than MFFS beneficiaries while rates of CABG were not significantly different. Rates varied widely at the HRR level among both MA beneficiaries and MFFS beneficiaries. While capitation through MA is associated with lower angiography and PCI procedure rates, the substantial geographic variation suggests that capitation alone will not lead to reductions in the variations seen in cardiovascular procedure use.

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“…5,7–12 Such variability has been interpreted as suggesting that similar patients are treated differently owing to factors such as local policy, practice culture, 12 or resource constraints. However, these studies have been limited by the inability to focus on patients with presumably similar preferences for end-of-life care.…”

mentioning

confidence: 99%

Variability Among US Intensive Care Units in Managing the Care of Patients Admitted With Preexisting Limits on Life-Sustaining Therapies

et al. 2015

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Relationship between Staff Perceptions of Hospital Norms and Hospital-Level End-of-Life Treatment Intensity

Abstract: Background-There are wide variations in hospital-level treatment intensity at the end of life that are not entirely explained by structural and market characteristics. Individual hospital microclimates must exist to perpetuate these practice variations.

Cited by 26 publications

References 10 publications

Variation in use of echocardiography among veterans who use the Veterans Health Administration vs Medicare

Variation in use of echocardiography among veterans who use the Veterans Health Administration vs Medicare

Geographic Variation in Cardiovascular Procedure Use Among Medicare Fee-for-Service vs Medicare Advantage Beneficiaries

Variability Among US Intensive Care Units in Managing the Care of Patients Admitted With Preexisting Limits on Life-Sustaining Therapies

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