Graph from The Dartmouth Atlas of Health Care 2003 – 2007
Percent of cancer patients receiving chemotherapy during the last 2 weeks of life.
The Dartmouth Atlas is a great quality tool for US health care. The idea of small area analysis dates back about 20 years when researchers noticed a considerable geographic variation in care. Now it has become an accepted technique to show how different regions adopt different practice patterns. The patterns are almost always disturbing since they mean US health care is not consistent thus not reliable. When such a map reflects billing for unnecessary care it is even more disturbing. Such is the case in the map above: some oncologists stop giving expensive chemotherapy when the situation is hopeless whereas other oncologists give chemotherapy until the patient is dead. If the oncologists did not derive financial benefit from chemotherapy one might be able to believe they were just giving a heroic effort in the face of death. But, given the financial incentive another interpretation would be prescribing something of no medical value for profit. It seems unlikely market forces would change this practice except to make it more widespread.
Performance status is a measure of how the patient is doing generally. If the patient is bedridden the performance status is very poor. In that very poor condition no chemotherapy helps, and in fact may hasten death. So, from a quality assurance standpoint close attention is needed to make sure oncologists are documenting performance status and acting accordingly.
The current thinking is when the performance status is bad it is time to stop chemotherapy and talk about hospice.