End-stage cancer patients in Minnesota are less likely to receive futile chemotherapy than patients in other states, and more likely to receive the comfort care that many patients want in their final days.
Minnesota hospitals are more likely to initiate hospice services and less likely to try last-chance treatments or send dying patients to the ICU, according to a new analysis by the Dartmouth Atlas Project, a widely cited research group associated with Dartmouth University. While one in four cancer patients nationally died in a hospital in 2010 — a fate most terminally ill patients want to avoid — that rate was only one in five in Minnesota.
The report shows progress nationally, but there’s a lingering gap between the aggressive care that hospitals are hard-wired to provide and the hospice approach that allows patients to die with less pain and in familiar surroundings.
“Care often reflects not what patients need or want, but the practice styles of a particular health system,” said Dr. David Goodman, a lead author of the report.
The Dartmouth Atlas has become an influential player in American health care over the past decade by using Medicare data to analyze which hospitals perform more aggressive procedures and bill the government most for their services.
The new study is particularly meaningful, Goodman said, because cancer tends to have a clearer trajectory and allows doctors to make accurate judgments about patients and their odds of survival.
So regional practice differences, which often explain variations in the performance of doctors and hospitals, can’t be explained away as easily in the case of cancer. There are no simple medical reasons, for example, why Washington, D.C., would have the highest rate of patients (14.5 percent) receiving life-sustaining care in the month before their deaths and Minnesota would have the lowest rate (4.9 percent).
Regional variations in care have often been linked to the fact that Medicare pays more in some states than in others; doctors in high-pay states have more financial incentives to order more medical services.
Minnesota hospitals, as a group, were quicker than those in other states to adopt hospice and palliative care, which prioritize comfort over life-sustaining interventions. That could explain the lower number of Minnesotans dying in hospitals or undergoing aggressive treatments, said Dr. Judith Kaur, an oncologist at Mayo Clinic.
‘What do you really desire?’
Even in Minnesota, however, there are disparities within cities and health systems. Allina Health’s United Hospital in St. Paul, for example, had only 12.5 percent of cancer patients admitted to intensive care in their final 30 days of life, compared to 23 percent at Allina’s Abbott Northwestern Hospital in Minneapolis. (Both were below the national average, 28.8 percent of patients.)
More recent data would likely show more uniformity across the hospitals, because Allina has been creating systemwide processes for meeting with cancer patients and completing advanced care directives, said Dr. Timothy Sielaff, president of Allina’s Virginia Piper Cancer Institute in Minneapolis.
Advanced care directives, he noted, help medical providers understand, “What do you really desire?”
One indicator that hospitals are thinking too late about end-of-life care is the rate of cancer patients who enroll in hospice three days before their deaths, according to the Dartmouth report. The service is unlikely to provide much comfort to patients or their families at that late point, said Dr. Ira Byock, author of the book “Dying Well,” who wrote an essay accompanying the Dartmouth report.
“Too many people are dying badly — dying in ways they would not have wanted and their families would not have wanted,” he said.
The Dartmouth data is showing progress in Minnesota and the United States, though. Comparing 2010 with aggregate data from 2003 through 2007, the report showed a 12 percent decrease in cancer patients dying in Minnesota hospitals and a 14 percent increase in cancer patients enrolled in hospice in their last month of life.