Health care providers in the San Diego region rank poorly in how they care for older, dying patients in three important ways, according to a national report released Wednesday.
First, Medicare beneficiaries with dementia should not have feeding tubes inserted during their last six months of life. Yet among those patients treated here, 7.8 percent had that unpleasant experience, more than the 6 percent national average. The region scored lower than 208 of the 306 hospital regions in the country.
Second, during their last six months of life, more beneficiaries spent time receiving aggressive, expensive care in intensive care units here than did beneficiaries in 252 other regions of the country, 4.4 days compared to the national average of 3.6.
And third, dying Medicare patients should not have to wait until their last three days of life before being enrolled in hospice services. Yet in San Diego, 16.8 percent did not receive hospice services until then. Despite the large number of hospice services available here, the region’s rating was equal to the national average.
What do the findings mean?
To Dr. William Mitchell, a medical oncologist who directs the Doris Howell Service for Palliative Medicine at UC San Diego, they indicate that doctors may be placing too much emphasis on technology.
“Consequently, there’s a little less emphasis on the human side of medicine, on caring for people instead of caring for diseases,” he said.
Dr. Julie Bynum, professor of The Dartmouth Institute for Health Policy & Clinical Practice, and lead author of the report, said the priority in care should be the patient’s and family’s experience.
“We must start having difficult conversations about what’s actually going to help,” she said. “Is this feeding tube going to help? If the answer is no, that’s a conversation we must have.”
Asked why this region scored poorly, Mitchell replied: “It’s certainly not a lack of resources,” a factor influencing disparities in other regions.
Rather, he said, “our health care culture tends to be very technologically focused, with an emphasis on treatments and interventions, on the latest and greatest, the new bells and whistles.”
That means too much focus on “the individual bacteria, on the individual pathophysiology and pharmacology. We forget we’re dealing with a human.”
The report’s statistics came from “Our Parents Ourselves: Health Care for an Aging Population,” the latest in a 20-year series from the Dartmouth Atlas. The research project analyzed 2012 Medicare claims nationally.
The three end-of-life rankings were among five highlighted by the researchers as those needing improvement across the country.
The San Diego region scored better on two measures of appropriate care. The area has the 37th lowest rate of mammography testing for beneficiaries over age 75, with 20 percent, better than the national average of 24.2 percent. It is 124th lowest in rates of prostate specific antigen testing with 18 percent, better than the national average of 19.5 percent. Neither test is recommended after one’s 75th birthday.
The data were culled from records of care provided for about 26 million Medicare fee-for-service beneficiaries. In this region, it reflects care for 195,000 people served by 20 hospitals, including two in Imperial County, one in Indio and two in Murrieta, in Riverside County. Medicare Advantage patients were not included, and rates for specific hospitals were not disclosed.
It was risk adjusted for age, gender and racial makeup.
Who’s at fault?
“I think the fault largely rests with physicians,” Mitchell said. “I think we could do a much better job being open and honest, and directly communicating with people to help them make decisions that will improve.”
As a palliative care specialist, he must wait until other doctors treating patients at UCSD call him in. “And the numbers that we see at UCSD, we’re called very late still. We would like to be involved much earlier during the course of the disease than we are on average.”
Dr. Karl Steinberg, medical director for Hospice by the Sea in Solana Beach and chairman of the Coalition for Compassionate Care of California, also blamed physicians for not referring patients to hospice faster.
“We have dozens of hospices, literally,” Steinberg said. “And the fact that we’re just in the middle of the pack on late referrals is a little surprising. I think intensive care physicians sometimes don’t have a culture of discussing these things; they’re in the business of prolonging life and go about their business.”
Too many ICU and primary care doctors aren’t interested in learning more about it, he said. “They’re comfortable just keeping people on a ventilator long term, and not taking the time to talk to families. I don’t mean to generalize; there’s plenty of good intensivists out there. But I think they’re in the business of providing invasive and intensive services to prolong life, and not really concerned with the quality of life.”
Role of payments
Some of the reason for delaying more appropriate end-of-life care concerns physician payment, Steinberg acknowledged.
“I don’t think that’s the primary thing, but you have to admit, an intensive care doctor who goes in and sees a person in the ICU who’s on a ventilator, passes their wand over them and listens to their heart and lungs, you know, they can bill $100 for that visit. Whereas spending 45 minutes at the bedside talking about end-of-life issues — is it time to consider taking the person off the ventilator? Just go to comfort care? They’re not going to get paid much for that.”
Money “is not at the top of their minds, but it’s somewhere on their minds,” Steinberg said.
“I hate to say bad things about my professional colleagues, but I think physicians are very misinformed about end-of-life issues.”
The region’s sizeable Hispanic population — the nation’s 19th largest — may influence longer stays in ICUs and late referrals, several experts suggested.
“In the Catholic population and Hispanic population, there tends to be perhaps more of a mistrust of the health care system, and also a push to prolong life at all costs. Even though that’s not what’s really in Catholic teaching, that seems to be what a lot of people feel,” Steinberg said. “If there’s a way to keep mom alive, put a feeding tube in her, put her on a ventilator, that’s what God would want.”
He added that with larger families, there may be “one holdout that makes it difficult for a physician to say, OK, we’re going to just concentrate on comfort care now.”
Dr. Timothy Corbin, Scripps Health’s medical director of hospice and palliative care services, said the lines of responsibility for which specific provider should have the conversation with dying patients is often unclear. For example, should it be the interventional radiologist or gastroenterologist who places the feeding tube, the dementia specialist, or the physician who refers the patient to get that intervention?
“Often I find as a palliative care physician that I’m the one being asked to have these conversations late in the disease course,” Corbin said.
He said that Scripps, like many hospitals across the country, has focused more attention on improving palliative care and hospice referrals since 2012, when data for this report were collected. “Absolutely we’ve improved” since then, he said.
Corbin faulted the fact that the San Diego region has a lot of independent nursing homes, facilities that “are not affiliated closely with hospitals,” as contributing to the problem of overly aggressive care at the end of life. Patients “are somewhat estranged from their families … and they’re in a facility that, when there’s a problem sends them to the hospital without clear parameters of what care restrictions would be. So by default, we do aggressive care until we figure that out.”
“Is our system in San Diego a good system, with nursing homes that really identify a sick patient at high risk for mortality, and giving them appropriate care at the end of life? Do we have that system in place? I’m not sure we do.”
Dr. Maida Soghikian, Scripps Health’s medical director of quality and a critical care specialist, said San Diego area hospitals perform “a lot of very advanced cutting edge medicine that is often for people at the last stages of life. ‘Here’s your chance.’ Not to say that places like Minnesota and other parts of the country don’t do that, but there are very high expectations (from) both the physicians and patients as to what medicine can actually do.”
The Dartmouth Atlas has used Medicare enrollment and claims data to show what it calls “glaring” variations in the delivery of medical services to seniors since the late 1990s.
Its findings were the subject of the seminal article by Dr. Atul Gawande in the June 2009 New Yorker, “The Cost Conundrum,” which showed enormous variations between spending per Medicare beneficiary in Miami and McAllen, Texas, compared with Rochester, Minnesota, and Grand Junction, Colorado.
“The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine,” Gawande wrote.
A major focus of the Dartmouth report was the wide variation nationally in the number of days per year that Medicare beneficiaries spend receiving health care services. For example, patients in East Long Island, New York, spent 24.9 days, where patients Marquette, Michigan, spent only 10.3 days. In the San Diego region, the number of days was 17.1, exactly the national average.
End-of-Life Health Metrics
Source: Dartmouth Atlas Project | Credit: Joe Yerardi, inewsource
The hospitals included in the Dartmouth Atlas report’s San Diego hospital referral region are:
- Alvarado Hospital (San Diego)
- El Centro Regional Med Ctr (El Centro)
- Fallbrook Hospital (Fallbrook)
- John F. Kennedy Memorial Hosp (Indio)
- Loma Linda Univ Med Ctr-Murrieta (Murrieta)
- Palomar Medical Center (Escondido)
- Paradise Valley Hospital (National City)
- Pioneers Mem Healthcare District (Brawley)
- Pomerado Hospital (Poway)
- San Diego Medical Center (San Diego)
- Scripps Green Hospital (La Jolla)
- Scripps Memorial Hosp-Encinitas (Encinitas)
- Scripps Memorial Hosp-La Jolla (La Jolla)
- Scripps Mercy Hospital (San Diego)
- Sharp Chula Vista Medical Center (Chula Vista)
- Sharp Coronado Hospital (Coronado)
- Sharp Grossmont Hospital (La Mesa)
- Sharp Memorial Hospital (San Diego)
- Southwest Healthcare-Rancho Springs (Murrieta)
- Tri-City Medical Center (Oceanside)
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