6 trends in end-of-life care for Medicare beneficiaries

Though issues remain, studies show a general national improvement in the delivery of end-of-life care, according to a report published by The Dartmouth Institute For Health Policy & Clinical Practice.

The Dartmouth Atlas Project report based its findings from CMS data on various traditional Medicare services for designated end-of-life care populations. The study populations include one based on assignment of decedents to the hospital they most frequently used in the last two years of life and the other based on the place of residence at the time of death. The report uncovered the following trends related to end-of-life care for Medicare beneficiaries.

1. Patients prefer to die at home, though historically, few have. A 1990s study cited by The Dartmouth Institute, The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment, revealed physicians often did not fulfill patients' requests regarding end-of-life care. For example, in its study of 479 patients, 391 said they preferred to die at home rather than in a hospital, but 216 of these 391 patients ended up dying in hospitals.

2. However, the percent of patients who spend their last days in a hospital is on the decline. The average rate of chronically ill Medicare beneficiary deaths in U.S. hospitals declined between 2003 and 2007, according to Dartmouth's findings:

  • 2003 — 32.2 percent of chronically ill Medicare patients died in the hospital
  • 2004 — 30.9 percent
  • 2005 — 29.9 percent
  • 2006 — 29.0 percent
  • 2007 — 28.1 percent

Aurora, Ill., saw the most significant decrease in hospital deaths (-17.5 percent), while the largest increase of 7.8 percent occurred in St. Cloud, Minn.

3. The local supply of medical resources has a significant influence on the amount of care delivered in a region. The phenomenon of "supply-sensitive care" occurs when physicians are uncertain about how to best treat patients with worsening chronic diseases and show an inclination to treat patients in hospitals, even when hospital care doesn't necessarily align with a patient's wishes. Essentially, regions with greater access to medical supply show higher rates of hospital admittance for end-of-life care, which in turn raises the chance for in-hospital deaths.

There was high variance in the admittance of chronically ill patients into intensive care during final hospital treatments. Thirty-one percent of chronically ill Medicare beneficiaries in New Brunswick, N.J., were admitted to ICU during their final hospitalization, while Des Moines, Iowa, had the lowest rate of ICU admittances with 10.1 percent.

The following shows the overall trend in the national average percentage of deaths associated with ICU admissions between 2003 and 2007.

  • 2003 — 18.6 percent
  • 2004 — 18.4 percent
  • 2005 — 18.0 percent
  • 2006 — 17.8 percent
  • 2007 — 17.6 percent

4. Hospice care is on the rise. Hospice care has benefits for both patients and hospitals. Hospice care outside of a hospital setting can help increase patients' quality of life during their final weeks and days and provide support for families. According to the report, some studies show that hospice care can also help lower costs for end-of-life care. The national average of hospice care days per patient has increased from 2003 to 2007, according to the report.  

  • 2003 — 12.4 hospice days per patient during the last six months of life
  • 2004 — 14.0 days
  • 2005 — 15.2 days
  • 2006 — 17.0 days
  • 2007 — 18.3 days

5. Like ICU care, hospice care rates vary by area. The increase in the use of hospice care is a significant indicator in the improvement of end-of-life care, though rates of hospice care vary from region to region, the report shows. The region with the most hospice days for patient in 2007 was Ogden, Utah, with an average of 39.5 days per patient in the last six months of life. Manhattan in New York had the fewest, with an average of 7.3.

6. Unnecessary and undesired end-of-life care comes at a high cost. In addition to the potential for diminishing the quality of life during a patient's final days and weeks, an important consequence of failing to adhere to patients' preferences for their end-of-life care is the delivery of unnecessary care, which can incur a high financial cost. About one-fourth of all Medicare spending is allocated to care for beneficiaries in their last year of life.

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