Variability in end of life care

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 …