They Call This Research?

The Dartmouth Health Atlas has come out with another one of its national breakdowns of Medicare claims, showing a wide variation between areas. This one is focused on end-of-life care for people with chronic illnesses. The authors do their usual job of putting vast amount of data into very colorful maps, which add up to absolutely no understanding of what is going on. They find, for instance, that:

Widespread regional variation persists in measures of end-of-life care. In 2007, the percentage of deaths in hospital varied by a factor of almost four across hospital referral regions, and the average number of hospice days per patient in the last six months of life varied by a factor of more than six.

For in-hospital deaths, the study finds that:

In 2007, the highest rates of death in hospital were in regions in and around New York City, including Manhattan (45.8%), East Long Island (41.9%) and the Bronx (39.9%)… In Minot, North Dakota, [by contrast,] only 12.0% of patients died in a hospital. Fort Lauderdale, Florida (19.0%) and Portland, Oregon (19.6%) were also among the regions with the lowest rates.

For lengths of hospital stays in the last six months of life, they found:

In 2007, patients in Manhattan spent, on average, 20.6 days in the hospital during their last six months of life, almost four times more than patients in Ogden, Utah, where the average was 5.2 days.

Now the authors claim that they have accounted for variations in populations and adjusted for that:

Although it is possible that some of the differences across hospitals may be explained by differences in patients’ preferences for care, studies show that regional variation in patient preferences overall explains very little of the variation in the intensity of end-of-life care. Differences in patient populations themselves also explain some of the variation in care. But by examining patients close to the end of life who are similarly ill with severe chronic diseases, and by adjusting for differences in age, sex, race and illness—as the data in this report have been adjusted—it is possible to account for most of the variation in patient populations, leaving variation caused by other factors, such as the availability of medical resources and the practice styles of health systems and clinicians. As this report shows, the remaining variation is substantial, both in the use of medical care and in trends in end-of-life care.

So the authors smugly assume that by adjusting for age, sex, race, and illness, they have eliminated any population differences that might contribute to different courses of treatment.

Golly, might there be anything else that distinguishes people in New York City from people in Ogden, Utah or Minot, North Dakota that might cause one population to be treated differently at the end of their lives? Let’s put on our thinking caps and noodle on this really, really hard.

Just maybe some people have different family structures and living conditions that enable them to stay at home during their last days, and just maybe these conditions are more favorable in Ogden and Minot than in New York. Conditions such as:

• Owning their own homes.
• Having intact families around, including adult children.
• Being strongly religious, especially Mormon in Ogden.
• Living in the same community all their lives.
• Residing in one or two story homes, rather than walk-up apartments.
• Having well-established networks of friends and civic associations.
• Enjoying a low rate of crime.

The Dartmouth researchers saw no need to ask about any of these conditions. They were content with things like race and gender. But like most health policy researchers, these folks view patients as slabs of flesh to be pushed around rather than as fully-realized adult human beings.

It is true they had the patients fill out a “patient preferences” questionnaire, but just because someone may “prefer” to die at home doesn’t mean they are practicably able to do so.

Now this is no obscure research project with little effect on real-world policy. Indeed, one of the authors, Elliot Fisher, is the primary force behind this administration’s devotion to Accountable Care Organizations. If the thinking going in to ACOs is as limited as the thinking in this paper, we can be assured that the needs of actual real-life patients will be well down the list of priorities.

One final thought: If you download the study and look at the pretty maps, you will notice an almost perfect correlation between the areas where people most often die in the hospital and the areas where people are most likely to vote for Democrats. So here is another variable that stands out — the political orientation of the population. Is it possible that Democratic patients have an entitlement mentality that demands they be taken care of, while Republican patients are more self-reliant? Inquiring minds want to know.

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