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Use of Intensive Care Services during Terminal Hospitalizations in England and the United States

¹ Department of Anesthesiology, Columbia University, New York, New York; ² ZD Associates, Perkasie, Pennsylvania; ³ Intensive Care National Audit & Research Centre, London, United Kingdom; ⁴ Center for Research on Health Care, University of Pittsburgh; and ⁵ The CRISMA Laboratory (Clinical Research, Investigation, and Systems Modeling of Acute Illness), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania

Correspondence and requests for reprints should be addressed to Hannah Wunsch, M.D., M.Sc., Department of Anesthesiology, Columbia University, 622 West 168th St, PH5-527D, New York, NY 10032. E-mail: hw2125{at}columbia.edu

Rationale: Despite broad concern regarding the provision and cost of health care at the end of life, country-specific patterns of care have rarely been compared.

Objectives: To assess the use of hospital and intensive care services during terminal hospitalizations in England and the United States, two populations with similar socioeconomic backgrounds and life expectancies.

Methods: Retrospective cohort study over a 1-year period (2001) using national (England) Hospital Episode Statistics, and regional (seven U.S. states) administrative discharge data as well as English and U.S. census data. We measured hospitalization rates and death rates during hospitalization with and without intensive care.

Measurements and Main Results: Age-adjusted acute hospitalization rates were 110.5 per 1,000 population in England versus 105.3 in the seven U.S. states, with the same mortality rate (0.9 per 1,000 population) in both countries. Of all deaths, 50.3% occurred in hospital in England and 36.6% in the United States, yet only 5.1% of all deaths in England involved intensive care, versus 17.2% in the United States, representing 10.1% of hospital deaths in England versus 47.1% in the United States. Greater intensive care use in the U.S. was most notable with older age; among decedents 85+ years, intensive care was used for 31.5% of medical deaths and 61.0% of surgical deaths in the United States versus 1.9 and 8.5% of deaths in England.

Conclusions: Despite similar overall hospitalization rates in England and the United States, there were marked differences in terminal hospitalizations, with far greater use of intensive care services in the United States, especially among medical patients and the elderly population.

Key Words: hospital mortality • intensive care units • terminal care • United States • England

AT A GLANCE COMMENTARY Scientific Knowledge on the Subject Despite broad concern regarding the provision and cost of health care among decedents, little is known about differences in patterns of care across countries. What This Study Adds to the Field Patterns of care among decedents differ dramatically in the United States and England. Half of all hospital deaths involve intensive care in the United States, compared with only 1 in 10 in England. The greatest limitations on intensive care during terminal hospitalizations in England occur among the elderly population and medical patients.

 

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