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Published January 04, 2011, 12:00 AM

Study examines cancer deaths

Number of people dying in hospital settings varies by region
A recent study on regional variations in health care found 29 percent of elderly cancer patients nationally die in hospitals.

By: Patrick Springer, INFORUM

A recent study on regional variations in health care found 29 percent of elderly cancer patients nationally die in hospitals.

The proportion of cancer patients dying within a hospital setting in the Red River Valley and nearby service areas generally was lower, although there were variations within service areas, according to an analysis by the Dartmouth Institute of Health Policy and Clinical Practice.

The variations among Medicare cancer patients – the best data set available – may be influenced by numerous factors, including individual patient choices for type of treatment and the availability and setting of hospice services.

Health policy analysts track the number of cancer deaths in hospitals as a rough indicator of how aggressive cancer treatment is for patients at the end of life.

In the Fargo service area, 26.4 percent of cancer patients died in a hospital from 2003-2007, compared to 22.6 percent in Bismarck, 29.4 percent in Minot, and 29.3 percent in Grand Forks.

Elsewhere in the region, rates generally were lower. In Sioux Falls, S.D., 22.3 percent of elderly cancer patients died in the hospital, compared to 18.6 percent in Rapid City, S.D., 21.1 percent in St. Cloud, Minn., and 21.4 percent in Rochester, Minn.

What accounts for the differences?

“Many of these choices are individual patient choices,” said Dr. John Thomas, medical director of Hospice of the Red River Valley, based in Fargo.

Some patients want aggressive cancer treatment even though the prognosis is grim, hoping they might somehow beat the odds and survive, he said, while others focus primarily on comfort care.

For instance, hospice recently cared for a 45-year-old man who has undergone three or four rounds of treatment, even though his chance of survival probably is low.

“He has small kids and wants to see them grow up,” Thomas said. A patient with different life circumstances might make a different choice.

Dr. Rhonda Ketterling, chief medical officer for Sanford Health’s Fargo region, agreed that lots of patient variables apply, including age and how aggressively a group of oncologists are in treatment practices.

The availability and setting of hospice services also can be a factor. Sanford Health has hospice cottages available to patients in Sioux Falls but not in Fargo, for instance.

Instead, Sanford has a palliative care unit in its hospital campus on South University Drive in Fargo.

“The family can be with them there in a more intimate setting,” compared to a normal hospital room, Ketterling said.

Nonetheless, the patient still is in a hospital, something that could explain why Fargo has a higher proportion of cancer patients dying in a hospital than Sioux Falls, according to the statistics analyzed in the Dartmouth Atlas Project.

The authors of the study, which examined records of more than 235,000 Medicare patients, concluded that in some hospitals, patients weren’t receiving adequate counseling about their prognosis and options.

That could lead some patients to “acquiesce to more aggressive care without fully understanding its impact on the length and quality of life,” said Dr. David Goodman, one of the lead investigators of the study.

Chemotherapy and other aggressive treatments can prolong life, but for frail, elderly patients – and any patient with advanced cancer – research has shown that such treatments have limited or no benefit, the Dartmouth report said.

Patient counseling and education do play an important role in end-of-life care, Ketterling said. “Maybe we’re not having those conversations with patients early enough in the process,” she added.

Regional variations in medical practices exist throughout health care, as the Dartmouth Atlas Project has documented for years. A goal of health care reform is to reduce the variations and to cluster around what data and studies determine to be “best practices.”

“What’s the root cause of the variation?” Ketterling asked, referring to the percentage of cancer patients dying in the hospital. “Is 18 percent best practice, or is it 23 percent? I don’t know, but we want to look at what is the best practice.”

Readers can reach Forum reporter Patrick Springer at (701) 241-5522