End of Life Care

The intensity of care in the last six months of life is an indicator of the propensity to use life-saving technology. The question of whether more medical intervention is better must be framed in terms of the potential gain in life expectancy for populations living in regions with greater intensity of intervention. Our research has provided evidence that populations living in regions with lower intensity of care in the last six months of life did not have higher mortality rates than those living in regions with higher care intensity.

More than 80% of patients say that they wish to avoid hospitalization and intensive care during the terminal phase of illness, but those wishes are often overridden by other factors. If more intense intervention does not improve life expectancy, and if most patients prefer less care when more intensive care is likely to be futile, the fundamental question is whether the quality of care in regions with fewer resources and more conservative practice styles is better than in regions where more aggressive treatment is the norm.

For rates pertaining to the last six months of life, the denominator was the Medicare population who died during the measurement year. Numerator events were determined using the Medicare Provider Analysis and Review (MedPAR) file. Rates for inpatient care per capita were computed using only the portion of the event (hospital stay or ICU stay) falling within the six-month period prior to death. Rates were age, sex and race adjusted using the indirect method. Event measures based on a count of fewer than 11 patients are not displayed for reasons of patient confidentiality. Rates with fewer than 26 expected events are also suppressed because of a lack of statistical precision. These cells are marked "na."


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The Dartmouth Atlas of Health Care is based at The Dartmouth Institute for Health Policy and Clinical Practice and is supported by a coalition of funders led by the Robert Wood Johnson Foundation, including the WellPoint Foundation, the United Health Foundation, the California HealthCare Foundation, and the Charles H. Hood Foundation.