Hospital End-of-Life Treatment Intensity Among Cancer and Non-Cancer Cohorts

Context. Hospitals vary substantially in their end-of-life (EOL) treatment intensity. It is unknown if patterns of EOL treatment intensity are consistent across conditions. Objectives. To explore the relationship between hospitals' cancer-and non-cancer-specific EOL treatment intensity. Methods. We conducted a retrospective cohort analysis of Pennsylvania acute care hospital admissions for either cancer or congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD) between 2001 and 2007, linked to vital statistics through 2008. We calculated Bayes's shrunken case-mix standardized (observed-to-expected) ratios of intensive care and life-sustaining treatment use among two EOL cohorts: those prospectively identified at high probability of dying on admission and those retrospectively identified as terminal admissions (decedents). We then summed these to create a hospital-specific prospective and retrospective overall EOL treatment intensity index for cancer vs. CHF/COPD. Results. The sample included 207,523 admissions with 15% or greater predicted probability of dying on admission among 172,041 unique adults and 120,372 terminal admissions at 166 hospitals; these two cohorts overlapped by 52,986 admissions. There was substantial variation between hospitals in their standardized EOL treatment intensity ratios among cancer and CHF/COPD admissions. Within hospitals, cancer-and CHF/COPD-specific standardized EOL treatment intensity ratios were highly correlated for intensive care unit (ICU) admission (prospective rho = 0.81; retrospective rho = 0.78), ICU lengths of stay (rho = 0.76; 0.64), mechanical ventilation (rho = 0.73; 0.73), and hemodialysis (rho = 0.60; 0.71) and less highly correlated for tracheostomy (rho = 0.43; 0.53) and gastrostomy (rho = 0.29; 0.30). Hospitals' overall EOL intensity index for cancer and CHF admissions were correlated (prospective rho = 0.75; retrospective rho = 0.75) and had equal group means (P-value = 0.631; 0.699). Conclusion. Despite substantial difference between hospitals in EOL treatment intensity, within-hospital homogeneity in EOL treatment intensity for cancer-and non-cancer populations suggests the existence of condition-insensitive institutional norms of EOL treatment. (C) 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.