America is doing a mediocre job of caring for its most seriously ill and vulnerable hospitalized patients. Palliative care programs are being put into place at a rapid pace in United States hospitals. However, despite high access in some states wide geographic variation remains a barrier to care for patients and families.
The study, America′s Care of Serious Illness: A State-by-State Report Card on Access to Palliative Care in Our Nation′s Hospitals,conducted by the Center to Advance Palliative Care (CAPC) and National Palliative Care Research Center (NPCRC), and published in the October issue of the Journal of Palliative Medicine, examines access at the state level in order to determine whether there is equitable care for seriously ill patients throughout the United States.
Where You Live Matters.
As the Dartmouth Atlas* researchers have often pointed out, “geography is destiny.” The same holds true when speaking of access to hospitals offering palliative care. If you′re living in the South, for example, you′re much less likely to find a hospital with a palliative care program. If you′re living in a region where there are only small hospitals (fewer than fifty beds), for example, your chances of having access to palliative care are extremely limited:
- The lowest prevalence of hospital palliative care programs is found in Mississippi (10 percent), Alabama (16 percent), Oklahoma (19 percent), Nevada (23 percent), and Wyoming (25 percent)
- The highest prevalence of hospital palliative care programs is found in Vermont (100 percent), Montana (88 percent), New Hampshire (85 percent), the District of Columbia (80 percent), and South Dakota (78 percent)
Size matters:
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Access to palliative care in small hospitals ranged from 0% in Louisiana, Maryland, Nevada, and New Mexico to 78% in Vermont, with a national average of 20.1%.
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Access in large hospitals (more than 300 beds) ranged from 0% in Nevada to 100% in twenty states. The national average was 75.4%.
There is considerable variation from state to state:
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States Receiving A Grades
Top Performers (programs in 81 to 100% of hospitals):
Vermont (100%); Montana (88%); New Hampshire (85%)
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States Receiving B Grades
On Their Way (programs in 61 to 80% of hospitals):
District of Columbia (80%); South Dakota (78%); Minnesota (75%); Missouri (73%); New Jersey (72%); Oregon (72%); Iowa (70%); Maine (69%); Michigan (69%); North Caroline (69%); Ohio (68%); Colorado (67%); Maryland (67%); West Virginia (67%); North Dakota (67%); Washington (65%); Wisconsin (64%); Virginia (63%); Kansas (61%)
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States Receiving C Grades
States in the middle (programs in 41 to 60% of hospitals):
Alaska (60%); Delaware (60%); Rhode Island (60%); Illinois (58%)
New York (58%); California (56%); Idaho (56%); Nebraska (56%)
Utah (56%); Connecticut (54%); Indiana (54%); Pennsylvania (54%)
Arizona (50%); Massachusetts (50%); Florida (49%); Hawaii (45%)
Tennessee (45%); Arkansas (41%)
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States Receiving D Grades
States that need significant improvement (programs in 21 to 40% of hospitals):
Georgia (38%); Kentucky (37%); New Mexico (33%); Texas (33%)
South Carolina (30%); Louisiana (27%); Wyoming (25%)
Nevada (23%)
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States Receiving Failing Grades
States with little or no access (programs in 0 to 20% of hospitals):
Oklahoma (19%); Alabama (16%); Mississippi (10%)
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Only three states did not improve at all since the Last Acts® report card of 2002:
Oklahoma; Alabama; Mississippi
Underserved Populations Also Show Disparities in Access to Palliative Care.
Public and sole community provider hospitals often serve as the only option for medical care for the 47 million Americans lacking health care coverage, as well as for communities that are geographically isolated:
- Only 41 percent of public hospitals provide their patients with access to hospital palliative care.
- Only 29 percent of sole community provider hospitals provide their patients with access to hospital palliative care.
For-Profit and Public Hospitals were Significantly Less Likely to Have Hospital Palliative Care Compared with Non-Profit Hospitals.
Not All Medical Schools are Affiliated with a Hospital that Provides a Palliative Care Program.
Improving access to palliative care for our nation′s patients and families requires that all future physicians receive training in the fundamentals of palliative care. This training needs to exist not only in the classroom but also in the hospital where medical students can experience the mentoring and role modeling at the bedside that is so critical to their professional development. At the time of this study:
- Five private medical schools were affiliated with hospitals not reporting a program: Albany Medical College, Boston University School of Medicine, Meharry Medical College, Tufts University School of Medicine, and Yale University School of Medicine. (Yale now has a program)
- Four states did not have a state-financed medical school that was affiliated with a hospital palliative care program: Connecticut, Mississippi, Nebraska and Nevada.
- Three states did not contain a medical school that is affiliated with any hospital palliative care program: Mississippi, Nebraska, and Nevada
A Fundamental Issue Facing the American Public is the Lack of Qualified Board Certified Physicians in Palliative Medicine.
In 2007, there were 2,883 physicians board-certified in palliative medicine (1 physician per 31,000 persons living with serious and life-threatening illness, or 1 physician per 432 Medicare deaths from chronic illness). In comparison, there are 16,800 cardiologists (1 per 71 heart attack victims) and 10,000 oncologists (1 per 145 patients newly diagnosed with cancer).
- The highest rates of board-certified palliative medicine physicians are in Hawaii, the District of Columbia, Alaska, New Mexico and Colorado
- The lowest rates of board certified palliative medicine physicians are in Mississippi, Arkansas, Nebraska, Idaho and South Dakota
There are also Implications for Patients and Families in the last six months of life.
Our data indicate that in states where there is greater access to palliative care programs, patients:
- Are less likely to die in the hospital
- Experience fewer ICU/CCU admissions in the last six months of life
- Spend less time in an ICU/CCU in the last six months of life
Conclusion
Although access to palliative care in the hospital setting is improving year-by-year, people living with a serious illness will still find significant disparities in their access to a hospital that provides palliative care. Focused efforts by hospital administration, the health care community, and policymakers are required to promote the development of quality palliative care programs in all hospitals, with special attention needed in small, rural, public and for-profit hospitals (see Recommendations for Action section of this report). This will result in a more efficient and effective use of hospital resources, and will enhance the quality of care delivered to our nation′s most seriously ill patients and their families.
* The Dartmouth Institute for Health Policy and Clinical Practice.
