In the past two decades, a spotlight has been focused on the care of chronically ill patients nearing the end of their lives. Although such care has improved since the 1990s, a recent brief on Medicare beneficiaries from the Dartmouth Atlas Project shows that further progress is needed and that quality of care, outcomes, and cost vary significantly from region to region and hospital to hospital.

In the brief, Goodman and colleagues reported data from 2007 to 2010. They identified significant improvements in care for Medicare patients in their last six months of life, with fewer overall days in the hospital (a 9.5% decrease in days per patient) and more hospice care (a 13.3% increase in enrolled patients), reflecting patients' wish to avoid procedures that would do little to improve the quality of or lengthen their lives. Although these improvements occurred at a rapid pace at some hospitals, at others they were barely evident.

Among academic medical centers, the variations in end-of-life care have been dramatic. Whereas some, such as NYU Langone Medical Center in New York City, decreased hospital days by nearly 30% between 2007 and 2010, others, like the University of California, Irvine, increased them by as much or more. Although hospice use increased more than 40% at 12 centers, patients at six others experienced a decline of more than 20% in hospice days. And despite an overall trend toward less hospital care in general, Medicare spending per patient in the last two years of life rose 15.2%.

The brief, Tracking Improvement in the Care of Chronically Ill Patients: A Dartmouth Atlas Brief on Medicare Beneficiaries Near the End of Life, is available at http://bit.ly/14NSOaH. For a detailed discussion of palliative and end-of-life care, see May's AJN Reports.-Laura Wallis