BMJ  2004;328:607 (13 March), doi:10.1136/bmj.328.7440.607

Paper

Use of hospitals, physician visits, and hospice care during last six months of life among cohorts loyal to highly respected hospitals in the United States

John E Wennberg, Peggy Y Thomson professor for the evaluative clinical sciences1, Elliott S Fisher, co-director2, Thérèse A Stukel, research director3, Jonathan S Skinner, John French professor of economics4, Sandra M Sharp, research associate1, Kristen K Bronner, research associate1

1 Center for the Evaluative Clinical Sciences, Dartmouth Medical School, 7251 Strasenburgh, Hanover, NH 03755-3863, USA, 2 VA Outcomes Group, White River Junction, VT 05001, USA, 3 Institute for Clinical Evaluative Sciences, Toronto, Canada, 4 Dartmouth College, Hanover, NH 03755, USA

Correspondence to: J E Wennberg john.wennberg{at}Dartmouth.edu

Abstract

Objective To evaluate the use of healthcare resources during the last six months of life among patients of US hospitals with strong reputations for high quality care in managing chronic illness.

Design Retrospective cohort study based on claims data from the US Medicare programme.

Participants Cohorts receiving most of their hospital care from 77 hospitals that appeared on the 2001 US News and World Report "best hospitals" list for heart and pulmonary disease, cancer, and geriatric services.

Main outcome measures Use of healthcare resources in the last six months of life: number of days spent in hospital and in intensive care units; number of physician visits; percentage of patients seeing 10 or more physicians; percentage enrolled in hospice. Terminal care: percentage of deaths occurring in hospital; percentage of deaths occurring in association with a stay in an intensive care unit.

Results Extensive variation in each measure existed among the 77 hospital cohorts. Days in hospital per decedent ranged from 9.4 to 27.1 (interquartile range 11.6-16.1); days in intensive care units ranged from 1.6 to 9.5 (2.6-4.5); number of physician visits ranged from 17.6 to 76.2 (25.5-39.5); percentage of patients seeing 10 or more physicians ranged from 16.9% to 58.5% (29.4-43.4%); and hospice enrolment ranged from 10.8% to 43.8% (22.0-32.0%). The percentage of deaths occurring in hospital ranged from 15.9% to 55.6% (35.4-43.1%), and the percentage of deaths associated with a stay in intensive care ranged from 8.4% to 36.8% (20.2-27.1%).

Conclusion Striking variation exists in the utilisation of end of life care among US medical centres with strong national reputations for clinical care.

Introduction

The frequency of use of hospitals, intensive care units, and physician visits among patients with chronic illness varies extensively across hospital regions in the United States. The variations are unrelated to population based measures of need but are closely associated with the per capita supply of hospital beds and physicians.1-4 The variations in frequency of use of these "supply sensitive" services are particularly striking during the last six months of life.1 These variations are of concern because they do not seem to reflect patients' preferences or rates of illness. Moreover, patients with chronic illnesses who live in regions with high rates of use do not seem to have better health outcomes.5-7 We have argued the need for academic medical centres to answer questions about how many hospital beds and physicians are needed to provide optimal care.5 8 An important first step is to obtain population based performance measures specific to academic medical centres. In this paper, we document end of life care among cohorts of patients enrolled in Medicare who receive most of their inpatient care at well known academic medical centres in the United States.

Methods

Selection of cohorts
Hospital specific utilisation measures are feasible because patients, particularly those with chronic illness, tend to receive most of their inpatient care from a given hospital.4 We identified patients who received most of their inpatient care during the last two years of their lives from a hospital that appeared on the 2001 list of "America's best hospitals" for geriatric care and for the treatment of three common chronic illnesses: heart disease, cancer, and pulmonary disease.9 By using Medicare's hospital admission files for patients who died in 1999-2000, we assigned decedents to the hospital used most often during the last two years of life. We generated utilisation measures for the cohorts assigned to the selected hospitals.

Outcome measures
The measures of utilisation during the last six months of life included the number of days spent in hospital ("hospital days"), the number of days spent in intensive care units ("ICU days"), the number of physician visits, the percentage of patients seeing 10 or more physicians, and the percentage of patients enrolled in a hospice. Measures of intensity of terminal care included the percentage of deaths occurring in hospital and the percentage of deaths involving a stay in an intensive care unit.

Statistical analysis
On the basis of the diagnoses that appeared on the record of the last hospital admission, we determined the presence of up to 11 chronic conditions and used these to adjust for differences among cohorts in underlying rates of disease. We calculated utilisation rates in the last six months of life and crude hospital specific rates. We adjusted the hospital and visit rates directly for age, sex, race, and illness by using regression models.10 The dependent variable was the total event count per decedent, and the independent variables were indicator variables for the study hospitals and for age, sex, race, and chronic condition.

We evaluated relations between hospital specific rates by using product-moment correlation. We used the coefficient of variation and interquartile and extremal range ratios to compare the degree of variation among utilisation measures. We also compared variation graphically by displaying the directly standardised rate for each hospital, expressed as a ratio to the mean rate among the 77 hospital cohorts. See bmj.com for details.

Final sample of hospital specific cohorts
Ninety two acute general hospitals appeared one or more times on the list of best hospitals for 2001. We excluded hospitals with fewer than 100 decedents with data for physician claims, leaving 77 hospital cohorts. Patient loyalty (defined as percentage of all days in hospital that occurred in the assigned hospital) tended to be strong. Among the 77 hospital specific cohorts, patient loyalty, measured over the two years before death, ranged from 64.6% to 91.9%, with a median of 82.5% and a mean of 81.4%.

Results

The table shows the characteristics of the study population. The intensity of care during the last six months of life and at the time of death varied substantially (fig). The average number of days spent in hospital during the last six months of life was more than 27 days in the highest ranked cohort and fewer than 10 days in the lowest ranked cohort. Average ICU days varied by a factor of six, from 1.6 to 9.5 days per person; physician visits varied by a factor of four, from less than 18 to more than 76 visits per decedent. The propensity to use multiple physicians varied from less than 17% of patients seeing 10 or more physicians in the last six months of life to more than 58% of patients. Deaths occurring in hospital ranged from less than 16% to more than 55%; deaths associated with a stay in an intensive care unit varied from less than 9% to more than 36%. Enrolment in a hospice varied among the cohorts from less than 11% of decedents to more than 43%.


View this table:
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  		Illness and demographic characteristics among patients assigned to 77 hospital cohorts. Values are numbers (percentages)

 


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  		Distribution of rates and statistical measures of variation for end of life care among 77 cohorts assigned to hospitals with national reputations for high quality. ICU=intensive care unit

 

We examined the intensity of care during the last six months for cohorts loyal to major teaching hospitals located in metropolitan regions with two or more major teaching hospitals. We ranked them according to the (unweighted) average number of patient days per decedent. By this measure, the hospitals located in Manhattan provided the most care. Other regions with high hospital day rates included Los Angeles, Philadelphia, and Washington DC. Patient cohorts loyal to the teaching hospitals in these regions also tended to have a higher frequency of physician visits, and a higher proportion saw 10 or more physicians. However, use of intensive care units varied. Hospitals in Minneapolis and San Francisco had low rates on all four measures of intensity of care in the last six months of life (see bmj.com).

The observed variation could have been generated by substitution between hospital use, physician visits, and hospice care. Enrolment in a hospice was inversely correlated with hospital days in the last six months of life (r = -0.41; P < 0.0002), the chance of dying in a hospital (r = -0.51; P < 0.0001), and the percentage of deaths occurring in association with a stay in the intensive care unit (r = -0.28; P = 0.012). However, the percentage enrolled in a hospice was not correlated significantly (P > 0.05) with fewer physician visits, seeing 10 or more physicians, or ICU days in the last six months of life. We found a strong positive correlation between the number of days spent in hospital and the number of physician visits within the last six months of life (r = 0.77; P < 0.0001).

Discussion

Academic medical centres in the United States with reputations for excellence differed dramatically in the care they provided to patients during the last six months of life.

What explains such variation?
Among regions, a direct relation exists between supply and utilisation of services. The frequency of use of physician services is strongly associated with the local workforce supply,1 11 12 and bed supply "explains" more than half of the variation in hospital admission rates for medical conditions.1

The key question is whether greater frequency of physician visits and hospital care for chronically ill patients results in better health outcomes. Two randomised trials of elderly patients found that more frequent office visits and more intensive primary care were associated with increased use of the hospital, no improvement in health or function, and a non-significant increase in mortality.13 14 We compared practice patterns and health outcomes across regions of the United States that were similar in baseline health status but that differed by 60% in overall utilisation of services.6 Greater frequency of use was associated with worse outcomes, suggesting that overuse of supply sensitive services was leading to harm, possibly because greater use of hospital and specialist care exposes populations to greater risks of medical errors.7

Limitations of the study
With the exception of hospice care, we were unable to evaluate the contribution of community care services. Interestingly, whereas hospice enrolment varied substantially among the 77 cohorts, we did not find that increased use of hospices led to less use of intensive care units or physician visits during the last six months of life. It was, however, associated with fewer deaths in hospital and, to a lesser degree, with a decrease in the chance that death was associated with a stay in an intensive care unit.

We had no information on preferences for end of life care or on satisfaction with the services provided, the effectiveness of pain control, or the degree of emotional or physical support provided by each healthcare system. The SUPPORT study documented deficiencies in these aspects of care and showed that the differences in hospital care were due neither to case mix nor to patients' preferences.15


What is already known on this topic

Population based rates of use of hospitals, intensive care units, and physician visits vary extensively across US regions, particularly during the last six months of life

Population based rates are uncorrelated with illness and patients' preferences but are closely associated with the supply of hospital beds and physicians

The outcomes of care are no better among the cohorts of patients with chronic illness who receive care in regions with higher rates of use of services

What this study adds

Population based rates of use of hospitals and physician services can be measured among populations loyal to specific hospitals

End of life care varies extensively among patient cohorts who receive most of their care from well known academic medical centres, even among those located in the same region

Hospital specific information opens the opportunity for academic medical centres to participate in studies to improve the quality and efficiency of care


We excluded patients who did not experience at least one hospital admission during their last two years of life. Adjusting our variables for the percentage of deaths without any hospital admission within two years of death had little impact on our results, and if anything tended to increase dispersion across hospitals. We also underestimated loyalty for medical centres that use affiliated hospitals, as this information was not available.

Generalisability
End of life measures provide a good indicator of how hospitals are treating all patients with chronic illness, not just those near death.6 Typically, hospital level comparisons are confounded by differences in case mix across communities. However, all patients in the last six months of life are similar with regard to one critical case mix adjuster—they are all dead within six months. Although we have found that regions allocating the least resources to patients at the end of life tend to have lower mortality and do better on other measures of quality for all of their patients,7 this association needs to be tested in countries where the frequency of acute hospital care and physician visits is less than in the United States.

This is an abridged version; the full version is on bmj.com

Contributors: See bmj.com

Funding: Grant support by the Robert Wood Johnson Foundation and the National Institute of Aging (1PO1AG19783-01).

Competing interests: None declared.

Ethical approval: Not needed.

References

  1. Wennberg JE, Cooper MM, eds. The quality of medical care in the United States: a report on the Medicare program. The Dartmouth atlas of health care 1999. Chicago, IL: American Hospital Association Press, 1999.
  2. Wennberg JE, Freeman JL, Culp WJ. Are hospital services rationed in New Haven or over-utilized in Boston? Lancet 1987;i: 1185-8.
  3. Wennberg JE, Freeman JL, Shelton RM, Bubolz TA. Hospital use and mortality among Medicare beneficiaries in Boston and New Haven. N Engl J Med 1989;321: 1168-73.[Abstract]
  4. Fisher ES, Wennberg JE, Stukel TA, Sharp SM. Hospital readmission rates for cohorts of Medicare beneficiaries in Boston and New Haven. N Engl Med 1994;331: 989-95.[Abstract/Free Full Text]
  5. Wennberg JE, Fisher ES, Skinner JS. Geography and the debate over Medicare reform. Published on Health Affairs website: www.healthaffairs.org/WebExclusives/Wennberg_Web_Excl_021302.htm
  6. Fisher ES, Wennberg DE, Stukel DA, Gottlieb D, Lucas FL, Pinder E. The implications of regional variations in Medicare spending: part 1, utilization of services and the quality of care. Ann Intern Med 2003;138: 273-87.[Abstract/Free Full Text]
  7. Fisher ES, Wennberg DE, Stukel DA, Gottlieb D, Lucas FL, Pinder E. The implications of regional variations in Medicare spending: part 2, health outcomes and satisfaction with care. Ann Intern Med 2003;138: 288-98.[Abstract/Free Full Text]
  8. Wennberg, JE. Unwarranted variations in healthcare delivery: implications for academic medical centres. BMJ 2002;325: 961-4.[Free Full Text]
  9. America's best hospitals. US News and World Report 2001;131(3).
  10. McCullagh P, Nelder JA. Generalized linear models, 2nd ed. New York: Chapman and Hall, 1989.
  11. Wennberg J, Gittelsohn A. Small area variations in health care delivery: a population-based health information system can guide planning and regulatory decision-making. Science 1973;182: 1102-8.[Abstract/Free Full Text]
  12. Welch WP, Miller ME, Welch HG, Fisher ES, Wennberg JE. Geographic variation in expenditures for physicians' services in the United States. N Engl J Med 1993;328: 621-7.[Abstract/Free Full Text]
  13. Wasson JH, Gaudette C, Whaley F, Sauvigne A, Baribeau P, Welch HG. Telephone care as a substitute for routine clinic follow-up. JAMA 1992;267: 1788-93.[Abstract/Free Full Text]
  14. Weinberger M, Oddone EZ, Henderson WG, for the Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmission. Does increased access to primary care reduce hospital readmissions? N Engl J Med 1996;334: 1441-7.[Abstract/Free Full Text]
  15. Pritchard RS, Fisher ES, Teno JM, Sharp SM, Reding DJ, Knaus WA, et al. Influence of patient preferences and local health system characteristics on the place of death: study to understand prognoses and preferences for risks and outcomes of treatment. J Am Geriatr Soc 1998;46: 1242-50.[Web of Science][Medline]
(Accepted 31 December 2003)


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