One in four Medicare patients with advanced cancer dies in hospital

A new report from the Dartmouth Atlas Project finds that although the use of hospice care for Medicare patients with advanced cancer is increasing many patients do not receive hospice care until they are literally on their deathbed, within three days of the end of life. Paradoxically, the updated data also find that in 2010, despite increases in the use of hospice care, more patients were also treated in intensive care units (ICUs) in their last month of life than in the period from 2003 to 2007.
This report finds that care for elderly patients with cancer continues to not necessarily reflect the patients’ preferences, but the styles of treatment in the regions or health care systems where they happen to receive cancer treatment. The report concludes that where patients with advanced cancer live continues to play an important role in the care they receive.
Although fewer Medicare patients with cancer died in the hospital in 2010 than in 2003-2007, aggressive treatment continues at the end of life. The findings show that just as many patients were likely to receive life-sustaining treatments, such as intubation, a feeding tube, or cardiopulmonary resuscitation, in the final month of life, or to undergo chemotherapy during the last two weeks of life, in 2010 as in 2003-2007.
The report examines trends in end-of-life care for advanced cancer patients across regions, academic medical centers, and National Cancer Institute-designated cancer centers. It is the first Dartmouth Atlas report with a longitudinal analysis of the care provided to Medicare patients with advanced cancer.
‘Our research continues to find that patients with advanced cancer are often receiving aggressive care until their final days, when we know that most patients would prefer care directed toward a better quality of life through hospice and palliative services. The increase in patients admitted to hospice care only days before death suggests that hospice services are often provided too late to provide much benefit.’ said David C. Goodman, M.D., M.S., co-principal investigator for the Dartmouth Atlas Project. ‘Fuller discussions with patients who have advanced cancer on their prognosis and options for care can lead to a better quality of life than many receive today.’
Overall, there were substantial changes across medical centers, cancer centers, and regions, but not in the same direction; some increased care intensity over time, while others provided less intensive care. This research looks at the last six months of claims records for 212,322 Medicare patients who died in 2010. To accompany the report, Ira Byock, M.D., offers recommendations for patients on how to work with their doctors to ensure their treatment plans align with their values and preferences. The findings in this brief were also reflected in a recent report by the Dartmouth Atlas Project and the California HealthCare Foundation, which finds that patients with advanced cancer in California are more likely to receive intensive treatments than in most other regions in the country.
Deaths occurring in hospitals
Between 2003-2007 and 2010, the percentage of Medicare patients with advanced cancer dying in hospitals and the average number of days they spent in the hospital before their deaths declined across most regions, medical centers, and cancer centers. In 2003-2007, 28.8 percent of patients with cancer died in a hospital; by 2010, the rate had dropped to 24.7 percent. In 2010, the highest rates of death in a hospital occurred in Manhattan, N.Y. (43%), Elmira, N.Y. (38.1%), McAllen, Texas (37.3%), and Meridian, Miss. (37.2%). Patients with cancer were far less likely to die in a hospital in Mason City, Iowa (10.5%), Bradenton, Fla. (11.9%), Greeley, Colo. (12.2%), and Sarasota, Fla. (12.2%).
Intensity of care in the last month of life
Overall, Medicare patients with cancer were significantly more likely to spend time in the ICU, as the percentage of patients admitted to the ICU during the last month of life increased by nearly 22 percent, from 23.7 percent from 2003-2007 to 28.8 percent in 2010. In addition, the average number of days spent in the ICU during the last month of life increased from 1.3 days to 1.6 days. In 2010, more than half of patients spent time in the ICU during the last month of life in McAllen, Texas (56.4%) and Miami (51.6%). Patients in Los Angeles (47.4%), St. Petersburg, Fla. (45%), and Chicago, Ill. (44.7%), were also likely to spend time in the ICU during the last month of life. Regions with low rates included Bismarck, N.D. (9.7%), Mason City, Iowa (10.7%), and Appleton, Wis. (10.7%).
Hospice care at the end of life
Medicare patients with advanced cancer were more likely to receive hospice care in 2010, as 61.3 percent of patients were admitted into hospice care during the last month of life, compared to 54.6 percent in 2003-2007. The percentage of patients admitted to hospice care during the last three days of life increased from 8.3 percent in 2003-2007 to 10.9 percent in 2010. In 2010, the regions with the highest rates of cancer patients receiving hospice care during the last month of life included Bend, Ore. (82.2%), Sun City, Ariz. (82%), and Cedar Rapids, Iowa (81.8%). Patients with advanced cancer in the Bronx, N.Y. (26.7%), Anchorage, Alaska (31%), and Manhattan, N.Y. (35.8%) were far less likely to receive hospice care.
The Dartmouth Atlas Project is located at the Dartmouth Institute for Health Policy & Clinical Practice and principally funded by the Robert Wood Johnson Foundation, with support from a consortium of funders that includes the WellPoint Foundation, the United Health Foundation, and the California HealthCare Foundation. Full data tables can be found atwww.dartmouthatlas.org.
Methodology
The report identified a 20 percent sample of all Medicare beneficiaries who died between the ages of 66 and 99 years during 2010. From these decedents, the report identified those with poor prognosis cancer diagnoses on at least one hospital claim or at least two clinician visits in the last six months of life. Decedents with hospitalization were assigned to the hospital providing the most cancer care hospitalizations in the last six months of life. All cancer decedents were also assigned to the hospital referral region of their residence.
About the Dartmouth Atlas Project
For more than 20 years, the Dartmouth Atlas Project has documented glaring variations in how medical resources are distributed and used in the United States. The project uses Medicare data to provide information and analysis about national, regional, and local markets, as well as hospitals and their affiliated physicians. This research has helped policymakers, the media, health care analysts and others improve their understanding of our health care system and forms the foundation for many of the ongoing efforts to improve health and health systems across America.
Lebanon, N.H. (September 4, 2013) ‘ The Dartmouth Institute for Health Policy & Clinical Practice