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

BMJ 2004; 328 doi: (Published 11 March 2004) Cite this as: BMJ 2004;328:607
  1. John E Wennberg, Peggy Y Thomson professor for the evaluative clinical sciences (john.wennberg{at},
  2. Elliott S Fisher, co-director2,
  3. Thérèse A Stukel, research director3,
  4. Jonathan S Skinner, John French professor of economics4,
  5. Sandra M Sharp, research associate1,
  6. Kristen K Bronner, research associate1
  1. 1 Center for the Evaluative Clinical Sciences, Dartmouth Medical School, 7251 Strasenburgh, Hanover, NH 03755-3863, USA
  2. 2 VA Outcomes Group, White River Junction, VT 05001, USA
  3. 3 Institute for Clinical Evaluative Sciences, Toronto, Canada
  4. 4 Dartmouth College, Hanover, NH 03755, USA
  1. Correspondence to: J E Wennberg
  • Accepted 31 December 2003


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.


  • Ethical approval Not needed.

  • Contributors All authors were involved in developing the methods for measuring hospital specific performance. TAS and SMS did the statistical analyses. JEW wrote many drafts of the paper, and all authors contributed to the final draft. JEW is the guarantor.

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

  • Competing interests None declared.

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