Organizational determinants of hospital end-of-life treatment intensity

There is substantial hospital-level variation in end-of-life (EOL) treatment intensity.

To explore the association between organizational factors and EOL treatment intensity in Pennsylvania (PA) hospitals.

Cross-sectional mixed-mode survey of Chief Nursing Officers of PA hospitals linked to hospital-level measures of EOL treatment intensity calculated from PA Health Care Cost Containment Council (PHC4) hospital discharge data. HOSPITALS: One hundred sixty-four hospitals, of which 124 (76%) responded to the survey.

: The dependent variable was an index of hospital EOL treatment intensity; the independent variables included administrative data-derived structural and market characteristics and 29 survey-derived hospital or ICU programs, policies, or practices.

: In models restricted to independent variables drawn from administrative sources (available for all 164 hospitals), bed size (P < 0.001), proportion of admissions among black patients (P < 0.001), and county-wide hospital market competitiveness (Herfindahl-Hirschman index) (P = 0.001) were independently associated with greater EOL treatment intensity (adjusted R = 0.5136). In models that additionally included hospital programs, policies, and practices (available for 124 hospitals), only an ICU long length of stay review committee (P = 0.03) was independently associated with greater EOL treatment intensity (adjusted R = 0.5357).

Information about hospital and ICU programs, policies, and practices believed relevant to the treatment of patients near the end of life offers little additional explanatory power in understanding hospital-level variation in EOL treatment intensity than administratively-derived variables alone. Future studies should explore the contribution of more difficult to measure social norms in shaping hospital practice patterns.