Chronically-ill Medicare patients spent fewer days in the hospital and received more hospice care in 2007 than they did in 2003, but their intensity of care increased as well, according to a report by the Dartmouth Atlas Project.
While in the hospital less, patients had many more visits from physicians, particularly specialists, and spent more days in intensive care units, as result of growth in intensive care and specialist capacity, the researchers said.
Intensive interventions can lower a patients’ quality of life and cost more, the researchers noted. About one-fourth of all Medicare spending stems from the last year of life, and much of the growth in Medicare spending is the result of the high cost of treating chronic disease, the authors noted. Following patient preferences for end-of-life care may reduce such spending.
The percentage of chronically-ill patients dying in hospitals and the average number of days they spent in the hospital before their deaths declined in most regions of the country and at most academic medical centers. In 2003, 32.2% of patients died in a hospital; by 2007, the rate had dropped to 28.1%. New York City and its boroughs had the highest rates, between 40-45%, while less metropolitan and rural areas could range from 12-20%.
Nationally, patients spent slightly fewer days in the hospital during the last six months of life in 2007 than in 2003, from 11.3 to 10.9 hospital days per patient. Again, geography mattered. In 2007, chronically-ill patients in Manhattan spent, on average, 20.6 days in the hospital during their last six months of life, but in Ogden, Utah, the average was 5.2 days.
Among those academic medical centers where patients spent less time in the hospital in 2007 than in 2003 were the University of Texas Medical Branch Hospitals in Galveston (-5.0 days), the University of Iowa Hospitals and Clinics in Iowa City (-5.0 days) and Tufts-New England Medical Center in Boston (-4.6 days). Ten academic medical centers had increases of at least two days, including Hahnemann University Hospital in Philadelphia (+6.8 days).
Also, chronically-ill patients were significantly more likely to be treated by 10 or more doctors in the last six months of life in 2007 than they were in 2003, as the national rate increased from 30.8% to 36.1%. In 2007, patients in Royal Oak, Mich. received the most intensive care by this measure, with 58.1% of patients seeing 10 or more doctors in the last six months of life. Other regions with high rates included Ridgewood, N.J. (57.6%) and Philadelphia (57.2%). Regions with low rates included Boise, Idaho (14.2%), Salt Lake City (15.0%) and Medford, Ore. (16.4%).
From 2003 to 2007, among the 35 academic medical centers for which data are available, 22 had increases in the percentage of patients seeing 10 or more doctors in the last six months of life. Emory University Hospital saw the largest growth in this rate, from 40.4% to 63.2%, while the University of North Carolina Hospitals in Chapel Hill had the largest decrease, from 45.0% to 35.2%.
Variations in the treatment of chronically-ill Medicare patients depend largely on the systems of care within different regions and hospitals, according to researchers.
“By providing insight into patterns of care, patients can look to these data to get a sense of where care is likely to be more or less intensive,” said Risa Lavizzo-Mourey, MACP, MBA, president and CEO of the Robert Wood Johnson Foundation, which funds the Dartmouth Atlas Project. “Providers can look for insights into potential savings they can achieve through improved care of chronic illness that allows patients to remain safely out of the hospital, and policymakers can identify regions that may have promising approaches.”
*This blog post was originally published at ACP Hospitalist*