Hospital End-of-Life Treatment Intensity Among Cancer and Non-Cancer Cohorts Amber E. Barnato, MD, MPH, MS, Elan D. Cohen, MS, Keili A. Mistovich, MD, MPH, Chung-Chou H. Chang, PhD Journal of Pain and Symptom Management Volume 49, Issue 3, Pages 521-529.e5 (March 2015) DOI: 10.1016/j.jpainsymman.2014.06.017 Copyright © 2015 American Academy of Hospice and Palliative Medicine Terms and Conditions
Fig. 1 Sample selection. Seven years of hospital discharge data included nearly 10 million admissions among nearly four million individual patients. After restricting the sample to in-state residents over age 21 with mutually exclusive cancer or non-cancer diagnoses, there were (a) 207,523 high probability of dying admissions and (b) 120,372 terminal admissions. These two cohorts overlapped by 52,986 admissions. PPD = predicted probability of dying; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease. Journal of Pain and Symptom Management 2015 49, 521-529.e5DOI: (10.1016/j.jpainsymman.2014.06.017) Copyright © 2015 American Academy of Hospice and Palliative Medicine Terms and Conditions
Fig. 1 Sample selection. Seven years of hospital discharge data included nearly 10 million admissions among nearly four million individual patients. After restricting the sample to in-state residents over age 21 with mutually exclusive cancer or non-cancer diagnoses, there were (a) 207,523 high probability of dying admissions and (b) 120,372 terminal admissions. These two cohorts overlapped by 52,986 admissions. PPD = predicted probability of dying; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease. Journal of Pain and Symptom Management 2015 49, 521-529.e5DOI: (10.1016/j.jpainsymman.2014.06.017) Copyright © 2015 American Academy of Hospice and Palliative Medicine Terms and Conditions
Fig. 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 on 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° line treat patients with cancer and CHF/COPD more similarly. Circles above the line treat CHF/COPD patients more intensely than cancer patients, whereas circles below the line treat cancer patients more intensely than CHF/COPD patients. (Note: one hospital's data point in Fig. 2, Panel e, falls outside the axis with a cancer-specific standardized ratio for tracheostomy of ∼8). CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ICU = intensive care unit; LOS = lengths of stay. Journal of Pain and Symptom Management 2015 49, 521-529.e5DOI: (10.1016/j.jpainsymman.2014.06.017) Copyright © 2015 American Academy of Hospice and Palliative Medicine Terms and Conditions
Fig. 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 on 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° line treat patients with cancer and CHF/COPD more similarly. Circles above the line treat CHF/COPD patients more intensely than cancer patients, whereas circles below the line treat cancer patients more intensely than CHF/COPD patients. (Note: one hospital's data point in Fig. 2, Panel e, falls outside the axis with a cancer-specific standardized ratio for tracheostomy of ∼8). CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ICU = intensive care unit; LOS = lengths of stay. Journal of Pain and Symptom Management 2015 49, 521-529.e5DOI: (10.1016/j.jpainsymman.2014.06.017) Copyright © 2015 American Academy of Hospice and Palliative Medicine Terms and Conditions
Fig. 1 Cancer and CHF/COPD admission PPD missingness, by year. Among cancer admissions 2001–2007, there are several statistically significant differences in demographic and clinical characteristics of admissions not missing PPD and those missing PPD, a handful of which may be clinically meaningful (age, race, insurance, emergency admission; see Table 2). Notably, 30-day mortality is statistically but not clinically different (11% vs. 11%), but 180-day mortality, conditional on survival to 30 days, is different, with those not missing PPD being more likely to live through 180 days than those missing PPD, which would bias our results toward the finding of survival benefit (e.g., systematically including patients with lower-than-average mortality). These patient demographic and clinical variables are accounted for in the mortality models. However, if they create systematic bias in the measure of a hospital's cancer-specific EOL intensity and of the relationship between intensity and survival, this may be worrisome. CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; PPD = predicted probability of dying; EOL = end of life. Journal of Pain and Symptom Management 2015 49, 521-529.e5DOI: (10.1016/j.jpainsymman.2014.06.017) Copyright © 2015 American Academy of Hospice and Palliative Medicine Terms and Conditions
Fig. 2 Correlation between hospital cancer-specific high probability of dying-based end-of-life treatment intensity and magnitude of the hospital's missing predicted probability of dying data for cancer admissions (Spearman correlation: 0.39). Journal of Pain and Symptom Management 2015 49, 521-529.e5DOI: (10.1016/j.jpainsymman.2014.06.017) Copyright © 2015 American Academy of Hospice and Palliative Medicine Terms and Conditions
Fig. 3 Correlation between hospital CHF/COPD-specific high probability of dying-based end-of-life treatment intensity and magnitude of the hospital's missing predicted probability of dying data for CHF/COPD admissions (Spearman correlation: 0.33). CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease. Journal of Pain and Symptom Management 2015 49, 521-529.e5DOI: (10.1016/j.jpainsymman.2014.06.017) Copyright © 2015 American Academy of Hospice and Palliative Medicine Terms and Conditions