Researchers Find End-of-Life Practices Vary Widely by Region

Older Americans prefer to die at home, but options vary by where they live

Boston – Most older adults facing end-of-life decisions express a preference to remain at home and receive care to manage their symptoms, rather than be admitted to the hospital or receive intensive care. National trends over the last two decades reflect this preference, with increasing numbers of Americans dying at home or in hospice care as hospital deaths declined. However, national statistics may miss important regional disparities in end-of-life care.

In a new study, researchers at Beth Israel Deaconess Medical Center’s (BIDMC) Center for Healthcare Delivery Science examined regional variation in site of death for older adults with chronic diseases from 2010 to 2016. The findings — which were published in JAMA Network Open — reveal that where chronically ill patients live may be an important determinant of whether their end-of-life care takes place in the hospital, ICU or hospice. The team found, for example, that more than a third of patients in Manhattan were hospitalized at end of life, compared to fewer than 14 percent of patients in Amarillo, Texas, Greeley, Colorado, or Ogden, Utah.

“While surveys show that older adults across the country commonly prefer to avoid hospitalization and intensive care at the end of life, we observed that rates of death in the hospital versus hospice vary significantly depending on where patients live,” said corresponding author Jason H. Maley, MD, a fellow in the Harvard combined Pulmonary and Critical Care fellowship at BIDMC and Massachusetts General Hospital. “We would like to explore the many factors that could drive this variation and create equity in end-of life care. For example, home hospice also requires significant effort from a patient's loved ones, who serve as caregivers, and the answer to quality end-of-life care is not simple or one-size fits all. Most of all, it should be care that aligns with a patient’s values and supports families.”

With colleagues Jennifer P. Stevens, MD, MS, Director of BIDMC’s Center for Healthcare Delivery Science, and Bruce E. Landon, MD, MBA, MSc, Professor of Health Care Policy at Harvard and Professor of Medicine at BIDMC, Maley analyzed Medicare claims to determine the percentage of patients who died in the hospital, hospital with intensive care unit admission, or in hospice in each of the United States’ 306 recognized regional healthcare markets.

Using data from more than 7 million patients diagnosed with at least one of nine chronic illnesses, the researchers found that the percent of patients dying in the hospital varied more than three-fold across regions of the country, and regions where a high percent of patients were hospitalized at the end of life had correspondingly low hospice use.

“It is our hope that future work that we and others perform can address the cause of this variation, so that all patients can experience the best care based on their personal wishes,” said Stevens, who is also Assistant Professor of Medicine at Harvard Medical School.

This work was supported in part by the Harvard combined pulmonary and critical care fellowship. The data used in this analysis were obtained from Dartmouth Atlas Data website, which was funded by the Robert Wood Johnson Foundation, The Dartmouth Clinical and Translational Science Institute, under award number UL1TR001086 from the National Center for Advancing Translational Sciences of the National Institutes of Health, and in part, by the National Institute of Aging under award number U01 AG046830.

Dr. Stevens reported receiving royalties from McGraw-Hill and UpToDate and grants from the Agency for Healthcare Research and Quality and the Doris Duke Charitable Foundation. No other disclosures were reported.