shows the characteristics of the study population. Of the 115 089 patients, 98 415 (85%) were chronically ill, many with two or more conditions. The intensity of care during the last six months of life and at the time of death varied substantially. The shows the standardised utilisation ratios and statistical measures of variation among the 77 hospital cohorts. Among the 77 hospital cohorts, the average number of days spent in hospital during the last six months of life was more than 27 days—almost a month—in the highest ranked cohort and fewer than 10 days in the lowest ranked cohort. Average ICU days varied by a factor of six, from 1.6 to 9.5 days per person; physician visits varied by a factor of four, from less than 18 to more than 76 visits per decedent. The propensity to use multiple physicians varied from less than 17% of patients seeing 10 or more physicians in the last six months of life to more than 58% of patients. The percentage of deaths occurring in hospital ranged from less than 16% to more than 55%; deaths associated with a stay in an intensive care unit varied from less than 9% to more than 36%. Enrolment in a hospice varied among the cohorts from less than 11% of decedents to more than 43%.
Illness and demographic characteristics among patients assigned to 77 hospital cohorts. Values are numbers (percentages)
Distribution of rates and statistical measures of variation for end of life care among 77 cohorts assigned to hospitals with national reputations for high quality. ICU=intensive care unit
examines the intensity of care during the last six months for cohorts loyal to major teaching hospitals located in metropolitan regions with two or more major teaching hospitals. They are ranked according to the (unweighted) average number of patient days per decedent. By this measure, the hospitals located in Manhattan provided the most care. Other regions with high hospital day rates included Los Angeles, Philadelphia, and Washington, DC. Patient cohorts loyal to the teaching hospitals in these regions also tended to have a higher frequency of physician visits, and a higher proportion saw 10 or more physicians. However, the use of intensive care units varied: the rates were high among the listed teaching hospital cohorts in Los Angeles, low in Washington, DC, and varied substantially according to specific hospital cohorts in Philadelphia and New York. Cohorts in Boston and St Louis exhibited considerable within area variation in hospital days and ICU days. By contrast, those in Minneapolis and San Francisco had low rates on all four measures of intensity of care in the last six months of life.
Table 2 Age, sex, race, and illness adjusted rates (95% confidence intervals) for hospital days, days in intensive care, and physician visits and percentage seeing 10 or more physicians during last six months of life among patient cohorts loyal to selected academic (more ...)
The observed variation could have been generated by substitution between hospital use, physician visits, and hospice care. Enrolment in a hospice was inversely correlated with hospital days in the last six months of life (r = - 0.41; P < 0.0002), the chance of dying in a hospital (r = - 0.51; P < 0.0001), and the percentage of deaths occurring in association with a stay in the intensive care unit (r = - 0.28; P = 0.012). However, the percentage enrolled in a hospice was not correlated significantly (P > 0.05) with fewer physician visits, seeing 10 or more physicians, or ICU days in the last six months of life. We found a strong positive correlation between the number of days spent in hospital and the number of physician visits within the last six months of life (r = 0.77; P < 0.0001).