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Variations in treatment intensity at end of life: review of evidence and policy and program implications

Ferguson, Robert (2017) Variations in treatment intensity at end of life: review of evidence and policy and program implications. Master Essay, University of Pittsburgh.

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Background: U.S. regions with higher intensity of end-of-life (EOL) care do not have greater patient demand for such treatment, nor do they have better outcomes, mortality, quality of care, or satisfaction. This inefficiency has significant public health importance, because resources for improving the public’s health are limited and must be used wisely. This review categorizes factors associated with variations in EOL treatment intensity and proposes targeted policy and program interventions. Methods: I searched Ovid MEDLINE for peer-reviewed studies that included patients 65 years or older, U.S. hospitals, and an analysis of factors affecting variations in EOL treatment intensity. I categorized these factors based on the socio-ecological framework (SEF). Results: The search produced 23 studies. The SEF individual level factors included age, race, ethnicity, gender, income, advance directives, and written medical orders. The SEF interpersonal factors included patient-doctor familiarity. The SEF community factors included the number of provider connections, primary care-centered networks, area-level competition, percent black admissions, and hospital care intensity level in the area. The SEF institutional factors included providers’ EOL decision-making norms, providers’ EOL treatment styles, organizational norms around do-not-resuscitate (DNR) orders, number of beds and providers, and for-profit compared to public institutions. The SEF policy factors included managed care compared to fee-for-service payment systems. Conclusion: To respond to these factors that explain variations in EOL treatment intensities, training programs for providers on palliative care and EOL conversations should be paired with organizational transformation strategies to affect skills, practices, and cultures. Policymakers should also consider value-based payment policies.


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Item Type: Other Thesis, Dissertation, or Long Paper (Master Essay)
Status: Unpublished
CreatorsEmailPitt UsernameORCID
Ferguson, Robertrof24@pitt.eduROF24
ContributionContributors NameEmailPitt UsernameORCID
Committee ChairBarron, GeraldGBARRON@pitt.eduUNSPECIFIEDUNSPECIFIED
Committee MemberBarnato, Amberamber.barnato@pitt.eduUNSPECIFIEDUNSPECIFIED
Committee MemberZionts, Nancyzionts@jhf.orgUNSPECIFIEDUNSPECIFIED
Date: 20 April 2017
Date Type: Publication
Publisher: University of Pittsburgh
Institution: University of Pittsburgh
Schools and Programs: School of Public Health > Health Policy & Management
Degree: MPH - Master of Public Health
Thesis Type: Master Essay
Refereed: Yes
Date Deposited: 14 Jul 2017 19:34
Last Modified: 31 Jul 2020 19:12


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