Monday, February 22, 2016

Dartmouth Atlas Shows Large Regional Disparities in EOL Care

by Karl Steinberg

The Dartmouth Atlas Project released its compelling new report, entitled “Our Parents, Ourselves” on February 17. The report discusses the aging population and its health concerns across the U.S., especially around end-of-life care, pointing out some areas where gains have been made and other areas where there is still much room for improvement. As with other Dartmouth Atlas releases, this fascinating report details geographic data among discrete regions nationwide—and not surprisingly, also demonstrates wide variation between regions in all of the parameters studied. For example, the percentage of people with dementia who have feeding tubes varied more than tenfold, from a low of 1.3% in Portland, OR, to 14% in Lake Charles, LA.

The authors did not attempt to define what ranges constituted “right care” for parameters like the number of ICU days in the last six months of life, but for most patients, it is intuitive that less ICU days generally suggests “better” care near the end of life. The same applies to number of healthcare encounters in the last six months of life, or number of different practitioners seen. Certainly for late hospice referrals (defined as admissions within three days of death), it would be ideal if nobody were referred for hospice so late—yet of course, it’s better to have some hospice than no hospice. And for other parameters like mammography in the elderly, the sweet spot probably isn’t zero since there are some very vigorous 75-year-olds who might benefit from screening even if the evidence doesn’t demonstrate a benefit in the whole universe of women 75 and up. For PSA screening in the elderly, though—considering that the evidence doesn’t even support doing it in younger people with longer life expectancy—probably zero would be a desirable goal.

As far as feeding tubes in advanced dementia, it’s pretty well established that they are not an appropriate intervention—they do not extend life and they do not improve quality of life, may be associated with numerous complications, etc., and are on the Choosing Wisely lists of “Don’ts” for AMDA—The Society for Post-Acute and Long-Term Care Medicine, the American Geriatrics Society, and the American Academy of Hospice and Palliative Medicine (I note in passing that the gastroenterology and interventional radiology organizations left it off their lists). Yet in real-life situations, it is often difficult to convince a family that it is not medically indicated to place a feeding tube in their demented loved one.

As we’ve grown to expect from the Dartmouth Atlas, the report is well-researched, colorful, and has plenty of references to evidence-based literature. There are other interesting demographic and insurance data by region that can really be intoxicating to drill down into, especially as they relate to our own local areas. For example, I was surprised at the worse-than-average percentage of late hospice referrals in San Diego County, considering the dozens of hospices and their high capacity and heavy marketing locally. The authors don’t give explanations for the disparities, but when we examine the data from our own areas, and how we shape up compared to our neighbors and to parts more distant, we should be looking for the reasons—and for ways to improve the care we give to our patients as they draw near to death.

Karl Steinberg. MD, CMD, HMDC, chairs the Coalition for Compassionate Care of California and serves as medical director for Hospice by the Sea in Solana Beach, CA, and for three skilled nursing facilities in San Diego County. He spends most of his time as a SNFologist and is best known for taking his dogs with him on rounds most days. You can find him on Twitter (@karlsteinberg)

Image Credits: Dartmouth Atlas "Our Parents, Ourselves" via fair use (education, critique). All Rights Re

Bynum JPW, Meara ER, Chang CH, Rhoads JM, Bronner KK. Our Parents,Ourselves: Health Care for an Aging Population. Lebanon, NH: The Dartmouth Institute of Health Policy and Clinical Practice, 2016.

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