title: Hospital end-of-life treatment intensity among cancer and non-cancer cohorts.
abstract: BACKGROUND
  Hospitals vary substantially in their end-of-life (EOL) treatment intensity. It is unknown if patterns of EOL treatment intensity are consistent across conditions.
  
  
  OBJECTIVE
  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 ρ = 0.81; retrospective ρ = 0.78), ICU lengths of stay (ρ = 0.76; 0.64), mechanical ventilation (ρ = 0.73; 0.73), and hemodialysis (ρ = 0.60; 0.71) and less highly correlated for tracheostomy (ρ = 0.43; 0.53) and gastrostomy (ρ = 0.29; 0.30). Hospitals' overall EOL intensity index for cancer and CHF admissions were correlated (prospective ρ = 0.75; retrospective ρ = 0.75) and had equal group means (P-value = 0.631; 0.699).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Department of Health Care Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA. Electronic address: barnae@upmc.edu.
authors.forename: Amber E
authors.initials: AE
authors.lastname: Barnato
authors.affiliation: Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
authors.forename: Elan D
authors.initials: ED
authors.lastname: Cohen
authors.affiliation: Children's Hospital of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
authors.forename: Keili A
authors.initials: KA
authors.lastname: Mistovich
authors.affiliation: Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA.
authors.forename: Chung-Chou H
authors.initials: CC
authors.lastname: Chang
mesh_terms: D000368:Aged; D003422:Critical Care / Q000379:methods* / Q000706:statistics & numerical data; D005260:Female; D006333:Heart Failure / Q000628:therapy*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D008297:Male; D009369:Neoplasms / Q000628:therapy*; D010414:Pennsylvania; D011446:Prospective Studies; D029424:Pulmonary Disease, Chronic Obstructive / Q000628:therapy*; D012189:Retrospective Studies; D013727:Terminal Care / Q000379:methods* / Q000706:statistics & numerical data
keywords: Terminal care; cancer; chronic obstructive pulmonary disease; congestive heart failure; end-of-life care; health services; hospital; intensive care; mechanical ventilation; utilization; variation