Hospital Culture and Intensity of End-of-Life Care at 3 Academic Medical Centers

Importance: There is significant institutional variability in the intensity of end-of-life care that is not explained by patient preferences. Hospital culture and institutional structures (e.g., policies, practices, protocols, resources), might contribute to potentially non-beneficial high-intensity life-sustaining treatments near the end of life.Objective: To understand the role of hospital culture in the everyday dynamics of high-intensity end-of-life care.Design: Comparative ethnographic study. Data were deductively and inductively analyzed using thematic analysis through an iterative coding process.Setting: Three academic hospitals in California and Washington that differed in end-of-life care intensity based on measures in the Dartmouth Atlas. Participants: Hospital-based clinicians, administrators, and leadersMain Outcome and Measure: Institution-specific policies, practices, protocols, and resources that shape hospital culture and their role in the everyday dynamics of potentially non-beneficial high-intensity life-sustaining treatments.Results: We conducted 113 semi-structured, in-depth interviews with inpatient-based clinicians and administrators between December, 2018 and June, 2022. Respondents at all hospitals described default tendencies to provide high-intensity treatments that they believed was universal in American hospitals. They also reported that pro-active, concerted efforts among multiple care teams were required to de-escalate high-intensity treatments. Efforts to de-escalate were vulnerable to being undermined at multiple points during a patient’s care trajectory by any individual or entity. Respondents described institution-specific policies, practices, protocols, and resources that engendered broadly-held understandings of the importance of de-escalating non-beneficial life-sustaining treatments. Respondents at different hospitals reported different policies and practices that encouraged or discouraged de-escalation. They described how these institutional structures contributed to the culture and everyday dynamics of end-of-life care at their institution.Conclusions and Relevance: Clinicians, administrators, and leaders at the hospitals we studied report that they work in a hospital culture where high-intensity end-of-life care constitutes a default trajectory. Institutional structures and hospital cultures shape the everyday dynamics by which clinicians may de-escalate end-of-life patients from this trajectory. Individual behaviors or interactions may fail to mitigate potentially non-beneficial high-intensity life-sustaining treatments if extant hospital culture or lack of supportive policies and practices undermine individual efforts. Hospital cultures need to be considered when developing policies and interventions to decrease potentially non-beneficial high-intensity life-sustaining treatments

Hospital Culture and Intensity of End-of-Life Care at 3 Academic Medical Centers.

ImportanceThere is substantial institutional variability in the intensity of end-of-life care that is not explained by patient preferences. Hospital culture and institutional structures (eg, policies, practices, protocols, resources) might contribute to potentially nonbeneficial high-intensity life-sustaining treatments near the end of life.ObjectiveTo understand the role of hospital culture in the everyday dynamics of high-intensity end-of-life care.Design, setting, and participantsThis comparative ethnographic study was conducted at 3 academic hospitals in California and Washington that differed in end-of-life care intensity based on measures in the Dartmouth Atlas and included hospital-based clinicians, administrators, and leaders. Data were deductively and inductively analyzed using thematic analysis through an iterative coding process.Main outcome and measureInstitution-specific policies, practices, protocols, and resources and their role in the everyday dynamics of potentially nonbeneficial, high-intensity life-sustaining treatments.ResultsA total of 113 semistructured, in-depth interviews (66 women [58.4%]; 23 [20.4%] Asian, 1 [0.9%] Black, 5 [4.4%] Hispanic, 7 [6.2%] multiracial, and 70 [61.9%] White individuals) were conducted with inpatient-based clinicians and administrators between December 2018 and June 2022. Respondents at all hospitals described default tendencies to provide high-intensity treatments that they believed were universal in US hospitals. They also reported that proactive, concerted efforts among multiple care teams were required to deescalate high-intensity treatments. Efforts to deescalate were vulnerable to being undermined at multiple points during a patient's care trajectory by any individual or entity. Respondents described institution-specific policies, practices, protocols, and resources that engendered broadly held understandings of the importance of deescalating nonbeneficial life-sustaining treatments. Respondents at different hospitals reported different policies and practices that encouraged or discouraged deescalation. They described how these institutional structures contributed to the culture and everyday dynamics of end-of-life care at their institution.Conclusions and relevanceIn this qualitative study, clinicians, administrators, and leaders at the hospitals studied reported that they work in a hospital culture in which high-intensity end-of-life care constitutes a default trajectory. Institutional structures and hospital cultures shape the everyday dynamics by which clinicians may deescalate end-of-life patients from this trajectory. Individual behaviors or interactions may fail to mitigate potentially nonbeneficial high-intensity life-sustaining treatments if extant hospital culture or a lack of supportive policies and practices undermine individual efforts. Hospital cultures need to be considered when developing policies and interventions to decrease potentially nonbeneficial, high-intensity life-sustaining treatments

A Typology of Existing Machine Learning–Based Predictive Analytic Tools Focused on Reducing Costs and Improving Quality in Health Care: Systematic Search and Content Analysis

BackgroundConsiderable effort has been devoted to the development of artificial intelligence, including machine learning–based predictive analytics (MLPA) for use in health care settings. The growth of MLPA could be fueled by payment reforms that hold health care organizations responsible for providing high-quality, cost-effective care. Policy analysts, ethicists, and computer scientists have identified unique ethical and regulatory challenges from the use of MLPA in health care. However, little is known about the types of MLPA health care products available on the market today or their stated goals. ObjectiveThis study aims to better characterize available MLPA health care products, identifying and characterizing claims about products recently or currently in use in US health care settings that are marketed as tools to improve health care efficiency by improving quality of care while reducing costs. MethodsWe conducted systematic database searches of relevant business news and academic research to identify MLPA products for health care efficiency meeting our inclusion and exclusion criteria. We used content analysis to generate MLPA product categories and characterize the organizations marketing the products. ResultsWe identified 106 products and characterized them based on publicly available information in terms of the types of predictions made and the size, type, and clinical training of the leadership of the companies marketing them. We identified 5 categories of predictions made by MLPA products based on publicly available product marketing materials: disease onset and progression, treatment, cost and utilization, admissions and readmissions, and decompensation and adverse events. ConclusionsOur findings provide a foundational reference to inform the analysis of specific ethical and regulatory challenges arising from the use of MLPA to improve health care efficiency