End-of-life care consumes a significant portion of health spending and can vary across geographies. The Dartmouth Atlas has looked at details of end-of-life care in several reports and most recently has updated trends from 2003-2007. (Dartmouth Report) The likelihood that a Medicare beneficiary died in a hospital decreased over this period, from 32.2% to 28.1%. The decline occurred in most hospital referral regions. The range was wide, from over 40% around New York to the teens in North Dakota and Portland, Oregon. The likelihood that a patient who died in the hospital also had an ICU stay also declined by about 1%, but continued to show wide variation, from 4% to 31%.
The number of days that a beneficiary spent in the hospital in the last 6 months of life dropped slightly, from 11.3 to 10.9 days, but also had substantial differences across regions, from 5 in Ogden, Utah to 20 in Manhattan. While the number of days declined, the intensity of care increased, including days in the ICU and number of specialists seen, with multiples of variation in each. The number of days in hospice increased from 12.4 to 18.3 days, with almost every area of the country seeing greater hospice use. A sub-analysis of academic medical centers found similar changes in trends of care and intensity.
In analyzing reasons for variation, the Dartmouth work continues to suggest that it reflects differences in supply of health care resources and provider practice pattern choices, rather than either patient demographics or patient preferences. These differences in care don’t appear to be associated with better outcomes and the researchers therefore conclude that being able to change the patterns in high spending, high intensity regions would result in substantial savings for Medicare and would also likely improve patient satisfaction.