(Photo/Kaiser Health News)

While fewer older Americans are dying in hospitals, new research suggests that doesn’t mean they’re getting less aggressive care in their final days.

Even as deaths in acute hospitals declined between 2000 and 2009, the use of intensive care units in the final 30 days of life increased, as did short-term hospice use, according to a study of Medicare beneficiaries published Tuesday in the Journal of the American Medical Association. The rate of changes to care for these patients, such as transitions within the last three days of life, also increased.

Dr. Joan Teno at Brown University’s medical school led the study. She says the increased use of hospice is encouraging, but worries about when seniors are referred to hospice.

“While there is greater access to hospice services, there’s also more ICU, more repeat hospitalizations, and more late transitions in the last three days of life,” Teno said during an interview. “The good news is that we are referring to hospice. The bad news is we’re referring to hospice in the last hours of life.”

Teno and her team analyzed findings of Medicare claims data from more than 800,000 seniors 66 years and older, who died in 2000, 2005, and 2009. While a 2010 report by the federal Centers for Disease Control and Prevention has looked at the patient’s location at death, researchers in this study examined beneficiaries’ medical claims for the last 180 days of life.

Hospice use at the time of death increased from nearly 22 percent in 2000 to 42 percent in 2009, the authors reported, but short stays of three days or less went from 22 to 28 percent. And 40 percent of those short stays came after time in a hospital ICU.

According to Teno, the study’s findings, particularly the increase in the number of short hospice stays following hospitalizations, suggest that aggressive care at the end of life is growing. “We really need to improve our referral patterns to make sure that people are receiving the appropriate and timely access to palliative care services at the end of the life,” she said.

Jon Radulovic, the vice president of communications of the nonprofit National Hospice and Palliative Care Organization, says the study adds to concerns about end-of-life care. “With the number of patients (in hospice) who die under seven days or less, it’s questionable whether the patient and family caregivers are able to fully benefit from the unique services that hospice offers,” he said.

With some provisions of the federal health law set to take effect in 2014, Teno sees an opportunity to hold institutions more accountable.

“The opportunity under health care reform is to really pay for quality and not pay for another day in the ICU,” she said. “Our fee-for-service system has probably resulted in overutilization of care and really, what we want to do is get the right care at the right time, for the right person, at the right location. And we want to respect the patient’s right to choose.”

This article was produced by Kaiser Health News with support from The SCAN Foundation.

The California HealthCare Foundation issued a new report on cancer in the state. (Flickr: briannaorg)

More than a million Californians are living with cancer, and a new report from the California HealthCare Foundation (CHCF) takes a look at how the disease has affected the population over time.

Stephanie Teleki, senior program officer at CHCF, says some of the most welcome news is about childhood cancers. While the likelihood of a child developing cancer has crept up, the rate of children in the state who die from cancer each year has decreased 21% over the last two decades.

Overall — looking at kids and adults — cancer mortality rates have fallen 22 percent since 1989 and rates of new cancer diagnoses have dropped 9 percent.

On the more sobering side, the report found persistent disparities across race. For instance the mortality rates in California for African Americans were 30 percent to 90 percent higher than in other groups for all cancers. And despite the fact that whites are more likely to be diagnosed with breast cancer, African Americans’ death rate from the disease is 40 percent higher. The inequity holds for prostate cancer, too: black men are two times more likely to die from that disease than whites.

The survey also looked at end of life care and cancer. CHCF took up the general issue of end-of-life care earlier in the year with a survey. The report showed that while 70 percent of Californians want to die at home, only 32 percent actually do so. Most Californians die in a hospital or nursing home.

Teleki says that has disturbing implications for cancer care in the state.

“Obviously the fact that California is 44th in the nation in the use of hospice care for cancer patients is very concerning,” she says. “We’re underutilizing end-of-life care — and especially hospice care — for cancer patients.”

Yet despite all the numbers in the new report, Teleki says it was very hard to find data for the report about cost and quality of cancer care in California.

“The California Cancer Registry is one of the most highly regarded state registries … so it is doing a great job doing what it was designed to do, which is be a public health surveillance tool,” says Teleki. “When it was created we were living in a different era. Now fast forward 20, 30, 40 years, we’re now very focused on quality measurement, transparency those kinds of things and that database wasn’t designed to do that.”

Teleki says an all-payer claims database (APCD) is one tool that the state could implement to start collecting information on cost and treatments. These so-called “rich datasets” would include information from people who have employer-based health insurance, Medicaid, Medicare or are uninsured. On the treatment side, it would include everything from inpatient care to outpatient care; medical and dental treatments.

States that have all-payer claims databases include Utah, Tennessee, Minnesota and Maine. Colorado is launching one this fall.

This post has been changed to reflect an update in the CHCF’s numbers regarding childhood cancer mortality.