The pneumonia deaths

A recent news report cited Community General Hospital for pneumonia death rates above the national average. The story was based on mortality statistics published by the Centers for Medicare and Medicaid Services (CMS). The mortality rates were mathematically adjusted for differences in patients' medical conditions, but the rates did not adjust for differences in mortality due to patients’ own do-not-resuscitate (“DNR”) orders.

The Post-Standard reported that for Medicare-covered pneumonia patients “the national mortality rate was 11.4 percent. Community General Hospital… had a pneumonia death rate above the national rate 15.1 percent.” In paragraph eight, the story appropriately quoted Fred Goldberg, MD, Community’s Chief Medical Officer, explaining that “these report cards do not account for...end-of-life preferences."

The distinction may be too subtle for headline writers.

Last year I wrote about CMS’ plans to add pneumonia mortality rates to its Hospital Compare website. I discussed Community’s past investigations into pneumonia deaths with respect to patients’ DNR orders – and I quoted “Mortality as a Measure of Quality: Implications for Palliative and End-of-Life Care” from the Journal of the American Medical Association (JAMA):

Mortality is a good quality measure for individuals with acute illness who are not supposed to die…However, mortality is a poor quality measure for the majority of patients with multiple chronic diseases who are near the end of their life, and may be engaged in…decisions that result in an earlier (or less delayed) death.

Following the recent news story, I again looked up the JAMA article. It said:

Treatments provided to seriously ill patients are often inconsistent with patients' underlying preferences….[T]here is a 10-fold variation in the rates of early do-not-resuscitate (DNR) orders across hospitals and dramatic variation in the proportion of all intensive care unit deaths preceded by withdrawal of life support….Such decisions may be relatively more common in the 600,000 hospital deaths that occur each year (over 50% of all hospital deaths) in patients aged 75 years or older who are at increased risk for accumulating multiple chronic illnesses.

During the period of time reported in the CMS data, the average age of the pneumonia patients who died at Community General was 83. As Dr. Goldberg reported, 93% of them had do-not-resuscitate orders.

Hospital patients who can't (or won't) leave

“Immigrants Facing Deportation by U.S. Hospitals” reports today’s New York Times about the extraordinary efforts of one Florida hospital to find continuing care, both in this country and in the patient’s native Guatemala, for an illegal immigrant who had become a de facto ward of the hospital.

Last week the Wall Street Journal reported that a Los Angeles’ ordinance makes it illegal for city hospitals to discharge to “skid row” homeless people who no longer need to stay in the hospital – this is called “patient dumping.” See “L.A. Law May Keep Homeless in Hospitals.” According to the Journal, many homeless patients simply “refuse to leave” a hospital.

Hospital, a new book by Julie Salamon, which is highly recommended, recounts the efforts of discharge planners at Brooklyn's Maimonides Hospital to find a place for a Chinese immigrant who, dying of cancer, no longer needed hospital-level care but otherwise had nowhere to go.

Hospitals nationwide deal with such situations all the time. Once a hospital has successfully cared for an individual’s acute care needs, that person may end up with nowhere to go because of deficiencies and inconsistencies in health care and social service systems.

A family may drop off an elderly parent in the emergency room, then leave on vacation or refuse to take the parent home after discharge from the hospital. If no nursing home will accept the patient, that individual becomes a border in the hospital, sometimes indefinitely.

Hospitals often help patients and families with nursing home placements by assisting with the complex Medicaid application process. It is not unusual, however, to find an individual or a family unwilling to disclose financial assets – unwilling even to sign a Medicaid application. This often means a nursing home will not accept the patient, who then remains inappropriately in the hospital.

These are called placement, transfer, or discharge problems, and few know about or understand them. As a result, such problems generate no political consensus toward a solution.

As a humane society, how do we assure appropriate levels of care for the homeless, for illegal immigrants, for the mentally challenged, as well as for those who may be willfully irresponsible?

According to the Journal: “[A]bout half the hospital’s homeless patients won’t sign discharge consent forms. ‘We can’t force them,’” says the discharge planner at one California hospital.

The Times reported that the Florida hospital’s care amounted to $1.5 million for the Guatemalan patient, but when it came to paying for nursing home or rehabilitation care, the hospital declined “to take out…[its] checkbook.” Why was that expected to be a hospital responsibility? Hadn't the hospital already discharged its (uncompensated) responsibility for acute care? Where is the nursing home industry's responsibility for continuing care? Where is the US government’s responsibility? Where is the responsibility of Guatemala for one of its citizens?

Government rules and media scrutiny are inconsistent among the sectors of the health care system. Thanks to unaligned incentives and inconsistent requirements, our disjointed health care system yields paradoxical results, as reflected in these stories from the Times and the Journal.