Monday, 31 March 2014

End of Life Overtreatment: Hospital Care Intensity (HCI) Index

Hospital Care Intensity (HCI) Index is a summary measure of the intensity of hospital resource consumption that is constructed, starting from the number of hospital stays and the number of visits to a specialist. Through this index, created by The Dartmouth Atlas, John Wennberg discusses the use of hospital services series by chronic patients for the last two years of their life, and notices a change in HCI up to 4 times between regions with more extreme data: New Jersey (NJ) and Salt Lake City (SLC).

HCI last two years of life in patients with chronic

The healthcare systems are all clear that if an 80 year old lady’s femur breaks she should be operated. After the intervention, she’ll have more or less successful results and this will determine the functional recovery of the patient, the permanent disability, or the death. But instead, when a patient with one or more chronic diseases grows older and his chronic diseases multiply or aggravate, then the response of almost all the systems is to provide disproportionate and costly hospital services, but all very uneven, as seen in the table above.

In this line, it now shows a comparison between one of the American teaching hospitals with the higher chronicity level for HCI, New York University Medical Center (NYUMC), with one showing the lowest HCI, Scott & White Memorial Hospital (SWMH). To set up the table, I chose the percentage of chronic patients who have died in the ICU or who died on a bed in a standard room, but had been admitted at least once in an ICU bed:

The tecnification of the end of life of chronic patients and frail elderly patients is one of the most unfortunate aspects of a medical system that although has managed to build very sophisticated and effective remedies to treat acute diseases, is not being able to provide appropriate services for patients with complex health and social needs.

In this post I wanted to show a few, US indicators, which are relatively simple to build, that aim to measure the attitude of the hospitals to the demands of decompensating chronicity. Despite some specific studies, such as the ones I have presented, the lack of indicators to measure this reality is an almost universal fact.

For my part, I have completed a survey to find out how many admissions for a non surgical cause of over 84 year old patients were made in hospitals of the Catalan public healthcare system, and I have obtained the following result:

This is not to say that people over 84 with fragility, or chronic diseases or both, should not be admitted to hospital, but this exercise gives me two thoughts:
  • The figure of 114 million, at least by our standards, is very high, and suggests that this amount could provide community level social and health programs certainly much more adjusted to this patient profile. Remember Sutton’s law? Well, this law suggests that we should look for resources in the waste and allocate them to actions with proven cost-effectiveness.
  • As it doesn’t seem feasible to suddenly remove this amount of hospital beds, we could consider a Sutton’s light law, which is what benchmarking gives us. If I check the data, I realize that the average percentage of hospitalized patients of over 84 years for non-surgical reasons, in relation to all the admitted patients for nonsurgical causes is 13.5%, and I also see an extraordinarily broad range between hospitals from 7.9% to 44.2 %. If at a first stage, the health centres with percentages above the average would be asked to aim in a couple of years to adjust their percentage to 13.5 %, a selective reduction of the most deviant could be achieved and after two years the global average would have been reduced significantly. Well, now we know that benchmarking is a very suitable instrument, especially when it is almost impossible to change cultures from within the business core business.

Sorry, but again I must insist on the book "Tracking Medicine " by John Wennberg. Oxford University Press 2010. It is very good.

Jordi Varela


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