Hospital end-of-life treatment intensity among cancer and non-cancer cohorts

Abstract

Context: Hospitals vary substantially in their end-of-life (EOL) treatment intensity. It is unknown if patterns of EOL treatment intensity are consistent across conditions.

Objectives: To explore the relationship between hospitals' cancer- and non-cancer-specific EOL treatment intensity.

Methods: We conducted a retrospective cohort analysis of Pennsylvania acute care hospital admissions for either cancer or congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD) between 2001 and 2007, linked to vital statistics through 2008. We calculated Bayes's shrunken case-mix standardized (observed-to-expected) ratios of intensive care and life-sustaining treatment use among two EOL cohorts: those prospectively identified at high probability of dying on admission and those retrospectively identified as terminal admissions (decedents). We then summed these to create a hospital-specific prospective and retrospective overall EOL treatment intensity index for cancer vs. CHF/COPD.

Results: The sample included 207,523 admissions with 15% or greater predicted probability of dying on admission among 172,041 unique adults and 120,372 terminal admissions at 166 hospitals; these two cohorts overlapped by 52,986 admissions. There was substantial variation between hospitals in their standardized EOL treatment intensity ratios among cancer and CHF/COPD admissions. Within hospitals, cancer- and CHF/COPD-specific standardized EOL treatment intensity ratios were highly correlated for intensive care unit (ICU) admission (prospective ρ = 0.81; retrospective ρ = 0.78), ICU lengths of stay (ρ = 0.76; 0.64), mechanical ventilation (ρ = 0.73; 0.73), and hemodialysis (ρ = 0.60; 0.71) and less highly correlated for tracheostomy (ρ = 0.43; 0.53) and gastrostomy (ρ = 0.29; 0.30). Hospitals' overall EOL intensity index for cancer and CHF admissions were correlated (prospective ρ = 0.75; retrospective ρ = 0.75) and had equal group means (P-value = 0.631; 0.699).

Conclusion: Despite substantial difference between hospitals in EOL treatment intensity, within-hospital homogeneity in EOL treatment intensity for cancer- and non-cancer populations suggests the existence of condition-insensitive institutional norms of EOL treatment.

Keywords: Terminal care; cancer; chronic obstructive pulmonary disease; congestive heart failure; end-of-life care; health services; hospital; intensive care; mechanical ventilation; utilization; variation.

Figure 1. Sample Selection

Seven years of hospital discharge data included nearly 10 million admissions among nearly 4 million individual patients. After restricting the sample to in-state residents over age 21 with mutually exclusive cancer or non-cancer diagnoses, there were 207,523 high probability of dying admissions (a) and 120,372 terminal admissions (b). These two cohorts overlapped by 52,986 admissions.

Figure 1. Sample Selection

Seven years of hospital discharge data included nearly 10 million admissions among nearly 4 million individual patients. After restricting the sample to in-state residents over age 21 with mutually exclusive cancer or non-cancer diagnoses, there were 207,523 high probability of dying admissions (a) and 120,372 terminal admissions (b). These two cohorts overlapped by 52,986 admissions.

Figure 2. Condition-specific Standardized End-of-Life Treatment Ratios

Scatter plots and density plots of cancer and CHF/COPD standardized (observed to expected treatment) intensity ratios among admissions ‘prospectively’ identified as being at the ‘end of life’ (e.g., at high probability of dying upon admission; panels a-f) and among admissions ‘retrospectively’ identified as being at the ‘end of life’ (e.g., terminal admissions; panels g-l). In the scatter plots, each circle represents a single hospital. Hospitals closer to the 45 degree line treat patient with cancer and CHF/COPD more similarly. Circles above the line treat CHF/COPD patients more intensely than cancer patients, while circles below the line treat cancer patients more intensely than CHF/COPD patients. (Note: one hospital’s data point in Figure 2, panel e, falls outside the axis with a cancer-specific standardized ratio for tracheostomy of ~ 8).

Figure 2. Condition-specific Standardized End-of-Life Treatment Ratios

Scatter plots and density plots of cancer and CHF/COPD standardized (observed to expected treatment) intensity ratios among admissions ‘prospectively’ identified as being at the ‘end of life’ (e.g., at high probability of dying upon admission; panels a-f) and among admissions ‘retrospectively’ identified as being at the ‘end of life’ (e.g., terminal admissions; panels g-l). In the scatter plots, each circle represents a single hospital. Hospitals closer to the 45 degree line treat patient with cancer and CHF/COPD more similarly. Circles above the line treat CHF/COPD patients more intensely than cancer patients, while circles below the line treat cancer patients more intensely than CHF/COPD patients. (Note: one hospital’s data point in Figure 2, panel e, falls outside the axis with a cancer-specific standardized ratio for tracheostomy of ~ 8).