RESUMEN
The purpose of this article is to review the literature and update analyses pertaining to the aggressiveness of cancer care near the end of life. Specifically, we will discuss trends and factors responsible for chemotherapy overuse very near death and underutilization of hospice services. Whether the concept of overly aggressive treatment represents a quality-of-care issue that is acceptable to all involved stakeholders is an open question.
Asunto(s)
Antineoplásicos/uso terapéutico , Cuidados Paliativos al Final de la Vida/estadística & datos numéricos , Neoplasias , Pautas de la Práctica en Medicina/estadística & datos numéricos , Garantía de la Calidad de Atención de Salud , Cuidado Terminal , Anciano , Humanos , Modelos Logísticos , Neoplasias/tratamiento farmacológico , Neoplasias/mortalidad , Neoplasias/terapia , Satisfacción del Paciente , Pautas de la Práctica en Medicina/tendencias , Programa de VERF , Cuidado Terminal/métodos , Cuidado Terminal/estadística & datos numéricos , Cuidado Terminal/tendenciasRESUMEN
OBJECTIVE: To evaluate measures that could use existing administrative data to assess the intensity of end-of-life cancer care. METHODS: Benchmarking standards and statistical variation were evaluated using Medicare claims of 48,906 patients who died from cancer from 1991 through 1996 in 11 regions of the United States. We assessed accuracy by comparing administrative data to 150 medical records in one hospital and affiliated cancer treatment center. RESULTS: Systems not providing overly aggressive care near the end of life would be ones in which less than 10% of patients receive chemotherapy in the last 14 days of life, less than 2% start a new chemotherapy regimen in the last 30 days of life, less than 4% have multiple hospitalizations or emergency room visits or are admitted to the intensive care unit (ICU) in the last month of life, and less than 17% die in an acute care institution. At least 55% of patients would receive hospice services before death from cancer, and less than 8% of those would be admitted to hospice within only 3 days of death. All measures were found to have accuracy ranging from 85 to 97% and 2- to 5-fold adjusted variability between the 5th and 95th percentiles of performance. CONCLUSIONS: The usefulness of these measures will depend on whether the concept of intensity of care near death can be further validated as an acceptable and important quality issue among patients, their families, health care providers, and other stakeholders in oncology.
