Influence of patient preferences and local health system characteristics on the place of death. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Risks and Outcomes of Treatment.
OBJECTIVE
To examine the degree to which variation in place of death is explained by differences in the characteristics of patients, including preferences for dying at home, and by differences in the characteristics of local health systems.


METHODS
We drew on a clinically rich database to carry out a prospective study using data from the observational phase of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT component). We used administrative databases for the Medicare program to carry out a national cross-sectional analysis of Medicare enrollees place of death (Medicare component).


METHODS
Five teaching hospitals (SUPPORT); All U.S. Hospital Referral Regions (Medicare).


METHODS
Patients dying after the enrollment hospitalization in the observational phase of SUPPORT for whom place of death and preferences were known. Medicare beneficiaries who died in 1992 or 1993.


METHODS
Place of death (hospital vs non-hospital).


RESULTS
In SUPPORT, most patients expressed a preference for dying at home, yet most died in the hospital. The percent of SUPPORT patients dying in-hospital varied by greater than 2-fold across the five SUPPORT sites (29 to 66%). For Medicare beneficiaries, the percent dying in-hospital varied from 23 to 54% across U.S. Hospital Referral Regions (HRRs). In SUPPORT, variations in place of death across site were not explained by sociodemographic or clinical characteristics or patient preferences. Patient level (SUPPORT) and national cross-sectional (Medicare) multivariate models gave consistent results. The risk of in-hospital death was increased for residents of regions with greater hospital bed availability and use; the risk of in-hospital death was decreased in regions with greater nursing home and hospice availability and use. Measures of hospital bed availability and use were the most powerful predictors of place of death across HRRs.


CONCLUSIONS
Whether people die in the hospital or not is powerfully influenced by characteristics of the local health system but not by patient preferences or other patient characteristics. These findings may explain the failure of the SUPPORT intervention to alter care patterns for seriously ill and dying patients. Reforming the care of dying patients may require modification of local resource availability and provider routines.
Department of Veterans Affairs Medical Center, White River Junction, VT, USA.
R S
RS
Pritchard
E S
ES
Fisher
J M
JM
Teno
S M
SM
Sharp
D J
DJ
Reding
W A
WA
Knaus
J E
JE
Wennberg
J
J
Lynn
D018806:APACHE; D000368:Aged; D001293:Attitude to Death; D001509:Bed Occupancy / Q000706:statistics & numerical data; D002391:Catchment Area, Health / Q000706:statistics & numerical data; D003430:Cross-Sectional Studies; D016208:Databases, Factual; D003657:Decision Making; D003695:Delivery of Health Care / Q000458:organization & administration; D005260:Female; D006699:Home Care Services; D006738:Hospices / Q000706:statistics & numerical data*; D006760:Hospitalization; D006784:Hospitals, Teaching / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data*; D015999:Multivariate Analysis; D009735:Nursing Homes / Q000706:statistics & numerical data*; D017060:Patient Satisfaction / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012959:Socioeconomic Factors; D013727:Terminal Care / Q000191:economics / Q000706:statistics & numerical data*; D014481:United States