Bmj Usa Editorial

Variability in end of life care

BMJ 2004; 328 doi: (Published 13 May 2004) Cite this as: BMJ 2004;328:E296
  1. Diane E Meier, director and professor of geriatrics and medicine (diane.meier{at}
  1. Center to Advance Palliative Care Mount Sinai School of Medicine New York, NY

    What does it tell us about quality?

    What is the “right” amount of medical care? In this issue of BMJ USA (p 231), Wennberg and colleagues document significant variability in care delivered by USacademic health centers to Medicare patients during the last six months of their lives. The study shows that the best quality academic teaching hospitals, as ranked by US News and World Report, vary in the amount and types of care they provide to the seriously ill. Medicare decedents' average days in hospital, days in intensive care, number of physician visits and physicians seen, hospice enrollment rates, and deaths in intensive care differed greatly among these highly ranked teaching hospitals.

    These findings are not unique to academic medical centers. The same investigators have documented similar regional variation in clinical practice in other hospital types, and the patterns suggest a strong influence on local practice patterns of opinion leaders, market forces, local medical culture, hospital and ICU bed availability, and access to specialists. It is perhaps not surprising that practice patterns within academic medical centers mirror those in surrounding regions, given that most physicians who train in these centers go on to practice in the same geographic region. Indeed, it may be reassuring that physicians continue to practice in the manner in which they were trained.

    Unfortunately, the fact that care type and amount are highly variable does not help us to understand what the right level of care should be. Evidence-based standards of practice that could guide physicians' treatment choices and practice patterns do not exist for many of the complex and chronic medical problems facing Medicare beneficiaries and their physicians. In the absence of such data, doctors continue to do what they were taught during their training and what the culture of clinical practice in their region expects. Evidence-based benchmarks for the right kinds of treatments and intensity of care are a necessary prerequisite to interpreting variability as de facto evidence of poor quality.

    Nevertheless, there is other solid evidence that the care of the seriously ill and dying needs improvement in US hospitals. Multiple studies have demonstrated high levels of pain, other symptom distress, poor doctor-patient communication about the goals of care and the medical decision making that should follow, and burdens on family care-givers.16 While medical advances have transformed many illnesses that once proved rapidly fatal into chronic conditions, improving the quality of this resulting longer life has been more difficult to achieve. These data plus the sharply rising costs of medical care for people living with chronic conditions have led to a more intensive focus on improving care quality at the bedside with the goal of delivering the right care to the right patient at the right time and place.

    While medical advances have transformed many illnesses that once proved rapidly fatal into chronic conditions, improving the quality of this resulting longer life has been more difficult to achieve.

    Improving the care of the seriously ill, the same population whose care is described in Wennberg et al's study, is the primary mission of the burgeoning palliative care movement in the US. Palliative care is medical care focused on relief of suffering for those with serious and advanced illnesses, support for doctor-patient communication, and delivery of coordinated, continuous, and comprehensive medical care for patients and their families.7,8

    Early studies suggest that good palliative care can improve the identification and treatment of symptom distress, promote doctor-patient communication, streamline medical decision making, and organize safe and effective care in the community.9,10 Data also suggest that palliative care programs in hospitals reduce utilization and costs, perhaps by helping patients make medical decisions concordant with their goals and by supporting continuity of quality medical care after a hospital stay.11 These programs have grown rapidly in hospitals in recent years, numbering over 950 in the 2002 American Hospital Association annual survey, an increase of 45% from 2000.12 A consortium of national palliative care organizations recently completed a consensus document on guidelines for best practices for palliative care programs in health care institutions,13 precisely to promote the kind of quality, consistency, and reduction in variability in care practices that Wennberg et al's study calls for.

    What does this variability in end of life care mean for US primary care physicians? At least two implications are clear. First, efforts to improve the care of persons with advanced chronic illness, while accelerating, are not consistently applied, even in leading teaching hospitals. More systematic approaches to the management of chronic and serious illness—through palliative care programs—should be encouraged by payers, accreditation and regulatory bodies, and the public. Second, clinical practice guidelines and standards, such as those recently developed for palliative care programs,13 should help to reduce variations in care. For physicians and the hospitals in which they practice, this development may help to advance consideration of—and ultimately, consensus on—what constitutes the right type and amount of care for patients living with serious chronic illnesses. Health services research on the impact of systematic, standardized approaches to common medical problems is needed to inform medical practice so that the right amount and the right kind of care can be scientifically defined and validated.


    • Competing interests None declared



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