Dartmouth Atlas Report: No consistency in care

Care varies markedly across regions, hospitals

Where they live can determine whether Medicare patients with advanced cancer die in a hospital or while receiving hospice care, according to the findings of a Dartmouth Atlas Project report, released in November 2010.

The report, "Quality of End-of-Life Cancer Care for Medicare Beneficiaries: Regional and Hospital-Specific Analyses," states in its introduction that "[t]his Dartmouth Atlas report examines how elderly patients with poor-prognosis cancer are cared for across regions and hospitals and finds remarkable variation depending on where the patients live and receive care."

"Even among the nation's leading medical centers, there is no consistent pattern of care or evidence that treatment patterns follow patient preferences," the report states.

The report's lead author is David C. Goodman, MD, MS, who is co-principal investigator for the Dartmouth Atlas Project and director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, NH.

Good information about the why variability of care exists comes from "a variety of other studies, including two Institute of Medicine reports," Goodman tells Medical Ethics Advisor.

"There are some facts that we know," as a result of such studies, he explains. "First, we know that generally, on average, patients receive much more aggressive treatment at the end of life and at the end of life with cancer than they prefer. Now, there are, of course, individual preference differences. They are important. They should be respected. But on average, patients are getting more care than they want, and it really degrades their quality of life.

"We also know that palliative care is underutilized in the United States — that many patients near the end of life don't receive adequate pain control or other adequate comfort measures," Goodman notes. "They're not afforded, oftentimes, the full opportunities to be at home and . . . to be communicating and as close as they would like with their families, because they were in the hospital or intensive care units."

Hospitals, he says, have also leaned toward underinvesting in palliative care services for patients at the facilities.

"They are sort of the poor relation to oncology and intensive care services," Goodman explains. "In many places, they are seen as an admission of defeat, which mischaracterizes both cancer, its treatment, as well as patient preferences. So, there are problems with inadequate investment in care that patients want, but there [are] also problems in health care providers' attitudes and understanding of patients' wants and needs."

The National Hospice and Palliative Care Organization (NHPCO) in Alexandria, VA, issued a news release following the Dartmouth Atlas Project's report on cancer care at end of life in this group of Medicare patients.

"The Dartmouth Atlas Project is to be commended for undertaking this thorough examination of end-of-life care for Medicare beneficiaries with advance[d] cancer," said J. Donald Schumacher, president and CEO of the NHPCO, in a news release. "While the findings of variation in care are not necessarily a surprise, one of the key messages that I take away from this report is the critical need for hospitals and all health care professionals to ensure that all patients are informed earlier about the course of an illness and the range of options available — options that include hospice and palliative care."

Schumacher continued, "It's important to recognize that this report is not a negative comment on care in our nation's hospitals or among academic medical centers, rather, it's a much needed reminder that health care professionals must work to help patients and families understand where the course of their illness may take them. And, when cure is not possible, it is our duty to offer the robust benefits that the hospice team can provide."

Ethical considerations from the report

There are "fundamental ethical" problems in health care delivery today in the United States, according to Goodman, who is also a practicing physician.

"One of them is that the paradigm that the role of physicians is to gather as much information as they can about their patients and then to provide them with a recommendation which is in the best interest of their patient," Goodman tells MEA. "There certainly are situations when the physician uniquely understands both the information and what represents best interest, or when decisions have to be made fantastically quickly, and we [place] trust [in] physicians to make the best call."

"But, in fact, there are many decisions in health care, and certainly at the end of life or when patients are not doing well with treatment, when it is presumptuous to assert that they uniquely understand what's in the best interest of patients," he explains. "And yet, this is done every day. It is a failure of ethical communication; it's a failure of providing adequate information to patients and family; and it leads to patients receiving care that is not the sort of care that they want."

Variation exists

Variation occurs not only across regions, which Goodman indicates reflects "the care provided by physicians and hospitals," but also across hospitals.

"It's interesting," Goodman says. "I think that every place is unique and special. We found just as much variation in the patterns of care across academic medical centers as we did across community hospitals."

This is a phenomenon that the Dartmouth Atlas project also has found when it engaged in studies of other aspects of care, he says.

"The notion that academic medical centers practice differently because they are places of teaching and research . . . is not well supported by studies that have been done measuring variation across different types of hospitals," Goodman says. "There are some slight differences that one might see, but they are really overwhelmed by the amount of variation that's seen within hospital type."

The researchers reviewed the records of 235,821 Medicare patients ages 65 or older with aggressive or metastatic cancer who died between 2003 and 2007. According to a news release issued on the project, in at least 50 academic medical centers, "fewer than half of these patients received hospice services. In some hospitals, referral to hospice care occurred so close to the day of death that it was unlikely to have provided much assistance and comfort to patients."

"The well-documented failure in counseling patients about their prognosis and the full range of care options, including early palliative care, leads many patients to acquiesce to more aggressive care without fully understanding its impact on the length and quality of life," Goodman also said in the news release.

Regional variation in care

In the United States, about 29% of patients with advanced cancer died in a hospital between 2003 and 2007, according to the report.

"Cancer patients were most likely to die in a hospital in the Manhattan hospital referral region, where 46.7% experienced death in a hospital," the report states. "The rates were also high in surrounding regions, including Ridgewood, New Jersey (42.8%), East Long Island, New York (42.5%), and Newark, New Jersey (41.1%)."

According to the report, those rates were about six times higher than the rate in the Mason City, IA. In that area, only 7% of cancer patients died in hospital.

"Cancer patients were also much less likely to experience a hospitalized death in Cincinnati (17.8%) and Fort Lauderdale, Florida (19.6%)," according to the report.

The report also sheds light on hospital admissions during the last month of life among hospital referral regions, indicating that "the percent of cancer patients hospitalized at least once during their last month of life varied by a factor of about 1.6" during the same study period.

"Nationally, 61.3% of cancer patients were hospitalized at least once during their last month of life," the report indicates.

"Cancer patients were mostly likely to be hospitalized during the last month of life in hospital referral regions in Michigan, including Detroit (70.2%), Royal Oak (69.4%), Pontiac (69.4%), and Dearborn (69.1%)," the report states.

However, "less than half of cancer patients" were hospitalized during their last month in Mason City, IA, at 44.9%, or San Angelo, TX, at 46.3%, Cedar Rapids, IA, and La Crosse, WI, at 49%.

The report also indicates hospital days during the last month of life among hospital referral regions, as well as intensive care admissions during the last month of life among hospital referral regions, among other categories examined.

In the latter category, for example, the report indicates that 40% of cancer patients who died during the study period were admitted to an ICU in the last month of life in Huntsville, AL, compared to 13% in Madison, WI, 14.3% in Portland, ME, and 14.6% in Minneapolis.

Variation across academic medical centers

"There is a remarkable amount of variation in the use of hospitals for elderly patients with poor prognosis cancer who are near the end of life," according to the report. "Even after controlling for cancer type, age, sex, and race, there were more than twofold differences in the number of days spent in hospitals and intensive care units in the last month of life."

Such differences should "stimulate teaching hospitals to further examine clinician practice styles and decision-making processes in relation to the evolving national norms of quality end-of-life care," the authors write. The report states that "the percent of cancer patients dying in a hospital varied threefold among patients receiving most of their care at academic medical centers."

Also, the authors write that "the likelihood of being admitted to the hospital during the last month of life among cancer patients varied from less than 50% to more than 75% across academic medical centers."


  • David C. Goodman, MD, MS, Co-Principal Investigator for the Dartmouth Atlas Project and Director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice, NH. E-mail: david.goodman@dartmouth.edu. Information: www.dartmouthatlas.org.