A national study of Medicare patients with cancer found big differences among hospitals and regions when it comes to how those patients spend the final weeks of their lives – and the same is true in Connecticut, on a smaller scale.
For example, about a quarter of elderly cancer patients died at Yale-New Haven Hospital, while at Bristol Hospital it was nearly 50 percent. At Middlesex Hospital in Middletown, just 19 percent of patients died in the hospital. The national average was about 29 percent.
The numbers come from a study done by the Dartmouth Institute for Health Policy & Clinical Practice. The report analyzed the records of more than 200,000 patients who were 65 or older with advanced cancer between 2003 and 2007.
There were smaller variations among Connecticut hospitals when it came to the number of days spent at a hospital or in hospice care in the last month of life. Each of the three regions of the state examined in the study – Bridgeport, Hartford and New Haven – were above the national average in hospital days, and below the national average for hospice days.
More than 60 percent of cancer patients in the three areas were hospitalized during the last month of their lives, putting Connecticut in line with the national average.
David C. Goodman, director of the Center for Health Policy Research at the Dartmouth Institute one of the study’s authors, said that across the country, the numbers show that doctors and patients aren’t having the right conversations about what patients want as they approach the end of their lives.
“I think that there are two important audiences here: hospitals can use this information to re-revaluate their progress in providing some care that improves quality of life as well as length of life. So this data is helpful to restart that conversation,” he said. “And patients can use this information to understand the different styles of practice in different hospitals.”
Those differences, he said, can be about attitude, when doctors spend too much time thinking about keeping their patients alive and not enough about how they might wish to die. They can also be a sign of investments made by hospitals and communities, both in hospital facilities and alternatives, such as hospice beds or home care.
Goodman said the data are “a good starting point for a conversation,” but emphasized that there’s no “average” experience for patients. He cautioned against reading too much into the percentages for each hospital, adding that patients and doctors need to be talking about options everywhere.
“It’s important that patients—no matter where they’re cared for—that they help to initiate conversations about living well as well as living long,” Goodman said.
Studies show, Goodman said, that most patients with terminal cancer prefer to die at home. Too often, he said, there’s no chance for them to have a frank discussion with their doctor about what they want.
And it’s not just about being in a hospital bed instead of in a hospice facility, he said. It’s crucial to manage pain, including when patients are still undergoing aggressive treatment, as well as to discuss when more chemotherapy or other treatment might lower quality of life without giving a patient more time.
“I think that it’s important to recognize that good care for patients with advanced cancer is not as simple as just having more hospice days,” Goodman said. “There’s not a simple correlation between more hospice days and fewer hospital days.”
Would be interesting to know if there are studies exploring the financial incentives and disincentives of hospitalization during end stage cancer care. Do MDs feel the need to increase the census of their floors (given the heavy competition between hospitals offering cancer care) and so balance the books? Are hospital administrators and MDs gaming the system to increase revenue at the cost of the patient’s comfort and quality of life at the end-stage of cancer? Tough questions that may offend but should be asked.