Posted on Wed, Apr. 20, 2011

After years of experts and patients saying people at the end of life might be more comfortable dying at home, a new study says that may finally be happening: fewer seniors in the United States and South Florida are dying in hospitals.

But the same survey finds that in the last months of life for seniors throughout the United States and especially in Miami, the trend is for more of them to see large numbers of specialists and to spend more time in expensive intensive care units.

Those are the results of the latest study from the Dartmouth Atlas, a project of the Dartmouth Medical School. The project for years has been using Medicare data to expose anomalies in healthcare costs and wide geographic disparities in expenses.

“Miami is practically off the charts,” says David Goodman, a Dartmouth researcher who was the lead author of the study. “It really continues to stand out” for having the highest costs and most extensive treatments in the last months of life, even when adjusted for age, ethnicity, race and severity of illness.

In particular, the study shows Miami leads the nation in seniors’ time spent in intensive care during the last six months of life – 10.7 days for the average Miami senior — compared with 0.7 days in Minot, N.D., the area with the least use of intensive care. In the Fort Lauderdale area, it was 7.2 days. The national average is 3.8 days, making Miami’s length of stay three times as long and Fort Lauderdale’s twice as long.

Disparities also exist by hospitals in the region. Mount Sinai Medical Center leads South Florida, with patients averaging 15.6 days in intensive care during their last six months. Aventura, Hialeah, Palmetto General and Metropolitan average more than 14 days. At the bottom: Cleveland Clinic in Weston (5.8), Mercy in Miami (6.1) and Homestead (7.7).

On Wednesday, Mount Sinai issued a brief statement that it’s not the hospital that makes the decisions: “We respect our patient’s preferences.”
The numbers are important for several reasons, researchers say. Intensive care often involves aggressive procedures, and surveys show that “patients have a strong tendency to want to avoid unpleasant procedures near the end of life,’’ says Goodman. Studies also show that three-quarters of Americans prefer to die in a “home or home-like environment” such as a hospice.

What’s more, “three clinical trials show that patients with advanced illness who received palliative and hospice care actually live longer than patients who receive aggressive treatment, which makes a lot of sense when you think of how fragile are the elderly when that treatments that purport to be life-sustaining, such as chemotherapy,” says Goodman.

Another crucial reason why these numbers are important: Medicare spending is a major reason for the nation’s crushing debt. Though this study doesn’t deal with costs, Goodman says earlier Dartmouth work has found that 32 percent of Medicare’s budget goes for care in the last two years of a senior’s life — expenses that often do little or nothing to postpone death.

The latest study, released last week, measures changes in the end-of-life treatment of chronically ill Medicare patients between 2003 and 2007. Delays in publishing the data are caused by the Atlas’ adjusting its figures for various factors, such as age and race. Other studies have consistently confirmed that other patients show the same treatment patterns as Dartmouth finds for seniors.

Over the five-year period, the study found the rates of deaths in hospitals dropped 12.8 percent nationwide. Locally, the rates dropped 13 percent in Miami and 19.9 percent in Fort Lauderdale.

Days in hospice increased 47 percent nationally, 50.6 percent in Broward and 15.5 percent in Miami over that time frame.

Once again, the differences between hospitals are major. At Mount Sinai, 43.5 percent of its longtime patients died there. The lowest figures in the region come from Memorial Pembroke and Cleveland Clinic hospitals, where 25.9 percent died in the facilities. The national average is 28 percent.

Goodman says Miami’s high costs are generally attributed to the area having a large number of hospital beds and a high number of physician specialists, causing both doctors and doctors to find ways of boosting business.

One reason patients may not get their wish to die at home could be “flaws in communications between physicians and patients,’’ says Goodman. Many doctors are trained to discuss treatments, not whether it is time to all end treatment, he said.

At Dartmouth’s medical center, an office has been set up specifically to counsel patients and families on end-of-life choices, often with specially trained nurses leading the discussions.

One puzzling aspect of the report: Fewer seniors dying in hospitals seems to indicate less aggressive care, but increased time in intensive care and more trips to specialists in the final months seem to indicate more aggressive care.

The Dartmouth data found that over the five-year period, the percentage of patients seeing 10 or more specialists in the last six months of life rose 17.2 percent nationally. In Broward, it increased 5.8 percent and in Miami 8.6 percent. Steven Ullmann, a health policy professor at the University of Miami, says there are several explanations for conflicting trends. One is that Medicare and other organizations are closely watching hospital mortality rates, and a high rate “is not a good thing,” meaning hospitals are motivated to push those in their final days into hospices.

Still, Ullmann says, hospitals and physicians might continue to seek ways to get more money from Medicare and related insurance. That, and technology improvements, could cause patients to be steered to intensive care until almost the end of their lives, he said: “So the motivations are complicated.”