BACKGROUND: There are wide variations in hospital-level treatment intensity at the end of life that are not entirely explained by structural and market characteristics. Individual hospital microclimates must exist to perpetuate these practice variations. OBJECTIVES: To determine whether a closed-ended survey based upon staff perceptions of informal norms regarding life prolongation, palliation, collaborative decision-making, and patient-doctor familiarity can identify hospital microclimates and to assess whether these norms are related to variation in end-of-life treatment intensity. DESIGN, PARTICIPANTS, AND MEASUREMENTS: Retrospective analysis of hospital discharge data at 11 purposively sampled Pennsylvania hospitals linked to a self-administered survey of 139 administrative and clinical staff fielded during site visits in 2004; measurements included year 2000 and 2004 rates of intensive care unit (ICU) admission, mechanical ventilation (MV), and hemodialysis among terminal hospitalizations at each hospital; survey respondent demographics, role, experience, and perceptions of their hospital's context and norms of end-of-life decision-making and treatment. RESULTS: The purposively sampled hospitals exhibited wide variation in rates of ICU admission (38.2%-84.4%), MV (13.7%-41.4%), and hemodialysis (0%-9.2%) among terminal admissions. All 139 administered surveys were returned for a response rate of 100%. For each of 4 factors created from 19 survey items, staff responses varied more between hospitals than within hospitals (p < or = 0.03). One factor, patient-doctor familiarity, was inversely correlated with terminal ICU admission (p < 0.001) and MV (p = 0.03). CONCLUSIONS: Discrimination of differences in microclimates related to norms of treatment intensity at the end of life is feasible, but greater specificity of measurement will be required to explain objective measures of terminal admission treatment intensity.
BACKGROUND: There are wide variations in hospital-level treatment intensity at the end of life that are not entirely explained by structural and market characteristics. Individual hospital microclimates must exist to perpetuate these practice variations. OBJECTIVES: To determine whether a closed-ended survey based upon staff perceptions of informal norms regarding life prolongation, palliation, collaborative decision-making, and patient-doctor familiarity can identify hospital microclimates and to assess whether these norms are related to variation in end-of-life treatment intensity. DESIGN, PARTICIPANTS, AND MEASUREMENTS: Retrospective analysis of hospital discharge data at 11 purposively sampled Pennsylvania hospitals linked to a self-administered survey of 139 administrative and clinical staff fielded during site visits in 2004; measurements included year 2000 and 2004 rates of intensive care unit (ICU) admission, mechanical ventilation (MV), and hemodialysis among terminal hospitalizations at each hospital; survey respondent demographics, role, experience, and perceptions of their hospital's context and norms of end-of-life decision-making and treatment. RESULTS: The purposively sampled hospitals exhibited wide variation in rates of ICU admission (38.2%-84.4%), MV (13.7%-41.4%), and hemodialysis (0%-9.2%) among terminal admissions. All 139 administered surveys were returned for a response rate of 100%. For each of 4 factors created from 19 survey items, staff responses varied more between hospitals than within hospitals (p < or = 0.03). One factor, patient-doctor familiarity, was inversely correlated with terminal ICU admission (p < 0.001) and MV (p = 0.03). CONCLUSIONS: Discrimination of differences in microclimates related to norms of treatment intensity at the end of life is feasible, but greater specificity of measurement will be required to explain objective measures of terminal admission treatment intensity.
Authors: Joan M Teno; Vincent Mor; Nicholas Ward; Jason Roy; Brian Clarridge; John E Wennberg; Elliott S Fisher Journal: J Am Geriatr Soc Date: 2005-11 Impact factor: 5.562
Authors: Elliott S Fisher; David E Wennberg; Thérèse A Stukel; Daniel J Gottlieb; F L Lucas; Etoile L Pinder Journal: Ann Intern Med Date: 2003-02-18 Impact factor: 25.391
Authors: Elliott S Fisher; David E Wennberg; Thérèse A Stukel; Daniel J Gottlieb; F L Lucas; Etoile L Pinder Journal: Ann Intern Med Date: 2003-02-18 Impact factor: 25.391
Authors: R S Broadhead; D D Heckathorn; D L Weakliem; D L Anthony; H Madray; R J Mills; J Hughes Journal: Public Health Rep Date: 1998-06 Impact factor: 2.792
Authors: S M Shortell; J E Zimmerman; D M Rousseau; R R Gillies; D P Wagner; E A Draper; W A Knaus; J Duffy Journal: Med Care Date: 1994-05 Impact factor: 2.983
Authors: J E Zimmerman; S M Shortell; D M Rousseau; J Duffy; R R Gillies; W A Knaus; K Devers; D P Wagner; E A Draper Journal: Crit Care Med Date: 1993-10 Impact factor: 7.598
Authors: Allan J Walkey; Amber E Barnato; Seppo T Rinne; Colin R Cooke; Meng-Shiou Shieh; Penelope S Pekow; Peter K Lindenauer Journal: Ann Am Thorac Soc Date: 2017-09
Authors: Joanna L Hart; Michael O Harhay; Nicole B Gabler; Sarah J Ratcliffe; Caroline M Quill; Scott D Halpern Journal: JAMA Intern Med Date: 2015-06 Impact factor: 21.873
Authors: Paul K Maciejewski; Andrea C Phelps; Elizabeth L Kacel; Tracy A Balboni; Michael Balboni; Alexi A Wright; William Pirl; Holly G Prigerson Journal: Psychooncology Date: 2011-03-29 Impact factor: 3.894
Authors: Alexi A Wright; Jennifer W Mack; Patricia A Kritek; Tracy A Balboni; Anthony F Massaro; Ursula A Matulonis; Susan D Block; Holly G Prigerson Journal: Cancer Date: 2010-10-01 Impact factor: 6.860
Authors: Daniel D Matlock; Peter W Groeneveld; Steve Sidney; Susan Shetterly; Glenn Goodrich; Karen Glenn; Stan Xu; Lin Yang; Steven A Farmer; Kristi Reynolds; Andrea E Cassidy-Bushrow; Tracy Lieu; Denise M Boudreau; Robert T Greenlee; Jeffrey Tom; Suma Vupputuri; Kenneth F Adams; David H Smith; Margaret J Gunter; Alan S Go; David J Magid Journal: JAMA Date: 2013-07-10 Impact factor: 56.272
Authors: Vinay Kini; Fenton H McCarthy; Sheeva Rajaei; Andrew J Epstein; Paul A Heidenreich; Peter W Groeneveld Journal: Am Heart J Date: 2015-07-26 Impact factor: 4.749