Lessons for End-of-Life Care in Hospitals
Seriously ill patients in hospitals typically receive intensive treatments. Yet, when such treatments are unsuccessful, patients may die with distressing symptoms while receiving burdensome care. Prior research has shown that medical care provided during the last year of life accounts for 10 to 12 percent of U.S. health care spending, and yet end-of-life care often may not align with patient or family wishes. Given these factors, more systematic measurement of the quality of hospital end-of-life care is needed.
A recent study examined the care provided to patients who died over a one-year period at Ronald Reagan UCLA Medical Center, a large teaching hospital known for providing aggressive care to patients who are critically ill. Although the study was designed to help the UCLA hospital improve end-of-life care, the findings may offer lessons for other hospitals and physicians who care for critically ill patients. The researchers analyzed the care provided to 496 adult patients who died at UCLA Medical Center after being hospitalized for at least three days between April 2005 and April 2006. Most of the patients were admitted to the hospital with end-stage diseases. Medical records were reviewed to assess the quality of care for 16 indicators of quality developed as part of the Assessing Care of Vulnerable Elders project, a RAND effort that developed quality measures for vulnerable older patients.
The review found that these patients received needed care for end-of-life issues about 70 percent of the time—a much higher score than has been found previously in studies of quality of care for vulnerable elders. Yet the results also identified a need for better communication between physicians and family members regarding the outlook and expectations for care when intensive treatments begin. The researchers recommended that such evaluation can be applied in other settings and that detailed quality-of-care information can identify deficiencies in care planning and symptom palliation to improve care for patients dying in the hospital.
Mark Your Calendar
Dr. Neil Wenger will be on Capitol Hill on Monday, September 13, to present “The Quality of Care for Patients Dying in the Hospital: Areas for Improvement Suggest Fundamental Problems in U.S. Healthcare”. The briefing will be from 1:00 p.m.–2:00 p.m. in 428a Russell Senate Office Building. For more information or to RSVP, please contact Kristy_Anderson@rand.org.
Dramatic Advances Have Improved the Identification, Treatment, and Prevention of Kidney Disease
An estimated 30 million Americans suffer from kidney disease. Historically, kidney disease has been defined and treated primarily in terms of kidney failure. Patients with kidney failure require either dialysis or a kidney transplant. Each year, nearly 500,000 people with kidney failure undergo these treatments in the United States at a cost of about $35 billion, billed mainly to Medicare. Recently, however, the disease has been redefined as chronic kidney disease (CKD), a progressive condition that culminates in kidney failure but can be treated and even prevented if detected early. Much of the innovative care for kidney disease is happening at CKD clinics, which represent a relatively new setting and approach to treatment. There is a need for practitioners and policymakers to have a better understanding of how these clinics are delivering care and the challenges they face to their viability. To address this need, a team of researchers from RAND, UCLA, and Charles Drew University conducted case studies at six CKD clinics, using site visits and telephone interviews.
The study findings highlight the benefits of CKD clinics and practices, including the advantages of early treatment; the use of clinical guidelines to identify patients for referral, organize practices, and build data systems; and the increasing possibility of using preemptive kidney transplantation, before patients require dialysis.
The results also point to challenges facing CKD practitioners. A principal challenge centers on reimbursement. Preventive care for CKD involves a multidisciplinary approach including multiple specialists, which can reduce costly interventions later. However, this care is not currently reimbursed by Medicare. Other challenges include a need for earlier referrals to kidney specialists, greater education among patients and primary care providers about the potential benefits of earlier care, and an approach to address racial and ethnic disparities in the CKD population.
The researchers offered several recommendations for addressing these challenges, including revised Medicare policies to reimburse for screening and to enable ongoing care as CKD progresses, improved access to care for ethnic minority populations, and greater integration of guidelines into clinical practice.
Fewer than Half of U.S. Adults Received Seasonal Flu Vaccination During the 2009–2010 Flu Season
Only 39 percent of adults in the United States received seasonal flu vaccinations during the 2009–2010 flu season. This was the main finding from a RAND survey, conducted in March 2010, to assess Americans’ use of the seasonal flu vaccine during the most recent flu season. The survey was designed to provide a snapshot for public health officials and other stakeholders of adult uptake of seasonal flu vaccinations. The survey included a nationally representative sample of more than 4,000 adults.
The survey also assessed vaccination rates among groups identified as facing the highest risks from flu. Among adults aged 18–49 with certain chronic conditions (asthma, heart disease, chronic lung disease, and diabetes), 45 percent received vaccinations. Vaccination rates were similar among two other high-risk groups: adults aged 50–65 (45 percent) and adults at greater risk of contact with other high-risk individuals, such as health care workers (47 percent). The only high-risk group to receive vaccinations at rates above 50 percent was adults aged 65 or older, of whom 65 percent were vaccinated. The survey results also showed variations by racial/ethnic group: Forty-three percent of white adults received vaccinations, compared with 32 percent of black adults and 30 percent of Hispanic adults.
Adults who were vaccinated were most likely to receive the vaccine at a doctor’s office or medical clinic (48 percent). Among all adults who did not receive vaccinations, the most commonly cited reasons were that they “did not need it” (28 percent) and that they “did not get around to it” (16 percent).
Neil S. Wenger
Neil S. Wenger is a professor of medicine in the Division of General Internal Medicine and Health Services Research at UCLA. He directs the Assessing Care of the Vulnerable Elders project, which develops quality of care measures aimed at vulnerable older persons and develops and implements quality improvement programs aimed at enhancing primary care rendered for older patients. He and colleagues at RAND and UCLA have developed the ACOVE-2 practice redesign intervention that has demonstrated improvement in care for falls and incontinence care among older patients in primary care. Dr. Wenger is director of the UCLA Health System Ethics Center and is chair of the Ethics Committee at the Ronald Regan UCLA Medical Center. He also is director of the NRSA Primary Care Research fellowship in the UCLA Division of General Internal Medicine. He is an active general internist and carries out research on the care of and decisionmaking for the older patient, quality of health care, and the empirical study of clinical ethics.
Read more about Neil S. Wenger »
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