America's Care of Serious Illness: A State-by-State Report Card on Access to Palliative Care in Our Nation's Hospitals

Over the last 10 years the number of palliative care teams in hospitals has more than doubled. Yet despite the myriad benefits of palliative care, as well as its recent growth, much more progress is needed. Millions of Americans facing serious illness do not yet have access to palliative care from the point of diagnosis throughout the course of illness. Availability also varies considerably by region and by state.

The following findings, taken from America's Care of Serious Illness: A State-by-State Report Card on Access to Palliative Care in Our Nation's Hospitals (www.capc.org/reportcard/), represents an update of the previous 2008 Report Card issued by the Center to Advance Palliative Care (CAPC) and the National Palliative Care Research Center (NPCRC). The report highlights the current prevalence of hospital palliative care in the United States by examining variation in access to palliative care at the state level.

The 2011 State-by-State Report Card Shows Improvement

The 2011 State-by-State Report Card updates our 2008 Report Card.¹ Reflecting data from the American Hospital Association Annual Survey Database™ for fiscal year 2009, we again examine prevalence and geographic variations in access to palliative care in U.S. hospitals. Specifically, in 2011 we examine:

• 1. Patient access to palliative care services in hospitals; and

• 2. Patient access to board-certified palliative care professionals (e.g., physicians and nurses).

Hospitals containing 50 or more beds are the primary focus of the 2011 Report Card. Hospitals with fewer than 50 beds see only a small number of patients with serious or life-threatening illnesses, and are therefore unlikely to be able to support the model of an interdisciplinary palliative care consultation team that includes, at minimum, a specialty level palliative care physician, nurse, and social worker. Also excluded from the study are rehabilitation hospitals; psychiatric hospitals; subacute and chronic care facilities; eye, ear, nose and throat hospitals; pediatric hospitals; hospitals under federal control (e.g., VA and military hospitals); hospitals located outside the 50 states and the District of Columbia; and hospitals that did not respond to the AHA Annual Survey Database™.

Findings in 2011 demonstrate considerable improvement since the 2008 Report Card. However, significant variation still persists from state to state. The 2011 analysis also demonstrates fluctuations in the number of hospital palliative care teams within a given state from year to year.

Table 1 presents the state-by-state findings of hospitals evaluated in this study—hospitals with 50 or more beds. Table 1 also shows the prevalence of palliative care teams among sole community provider hospitals, larger hospitals with 300 or more beds and small hospitals with fewer than 50 beds.

Table 1.

Grades by State

States receiving an A grade
District of Columbia	100%
Maryland	90%
Minnesota	89%
Nebraska	93%
Oregon	88%
Rhode Island	88%
Vermont	100%
Washington	83%
On their way (programs in 61% to 80% of hospitals): States receiving a B grade
Arizona	69%
California	67%
Colorado	73%
Connecticut	72%
Florida	62%
Idaho	63%
Illinois	67%
Indiana	63%
Iowa	61%
Maine	71%
Massachusetts	67%
Michigan	76%
Missouri	75%
Montana	67%
Nevada	69%
New Hampshire	77%
New Jersey	80%
New York	75%
North Carolina	75%
North Dakota	67%
Ohio	80%
Pennsylvania	67%
South Dakota	78%
Virginia	78%
Wisconsin	74%
States in the middle (programs in 42% to 60% of hospitals): States receiving a C grade
Georgia	43%
Hawaii	58%
Kansas	47%
Kentucky	55%
Louisiana	43%
New Mexico	44%
South Carolina	51%
Tennessee	52%
Texas	42%
Utah	60%
West Virginia	55%
Wyoming	50%
States that need significant improvement (programs in 28% to 38% of hospitals): States receiving a D grade
Alabama	28%
Alaska	29%
Arkansas	38%
Oklahoma	30%
States with little or no access (programs in 0% to 20% of hospitals): States receiving an F grade
Delaware	20%
Mississippi	20%

What Are the Key Predictors of Access to Palliative Care?

As we have seen in other areas of our health care system, we found wide geographic variation in access to palliative care services. Factors predicting the presence of a hospital palliative care team have not changed markedly since the 2008 Report Card.

• ➢ Large hospitals with 300 or more beds are more likely to report a palliative care team (85%).

• ➢ Public hospitals (54%), for-profit hospitals (26%), and sole community provider hospitals (37%) are less likely to report a palliative care team.

• ➢ On average, midsize (50–300 beds) and large hospitals (over 300 beds) are more likely to be not-for-profit.

Improvements since the 2008 Report Card

Since our last report, the overall prevalence of hospital palliative care teams among hospitals with 50 or more beds increased 13.3% in the Midwest, 21.7% in the Northeast, 23.7% in the South, and 29.3% in the West. The cumulative national average is 63% (1568/2489 study hospitals).

There have also been improvements at the state level. In 2008, the 11 states with the lowest prevalence rates were: Mississippi (10%), Alabama (16%), and Oklahoma (19%), Nevada (23%), Wyoming (25%), Louisiana (27%), South Carolina (30%), Texas (33%), New Mexico (33%), Kentucky (37%), and Georgia (38%).

Today, only Delaware and Mississippi get an F (20%). However, Mississippi demonstrated substantial improvement since 2008, doubling its prevalence from 10 to 20%. Alabama increased from 16 to 28%, and Oklahoma increased from 19 to 30%. Seven states improved their grades from a D to a C: Georgia, Kentucky, New Mexico, Texas, South Carolina, Louisiana, and Wyoming. Nevada saw dramatic gains, rising from a D to a B grade.

States getting an A nearly tripled from three in the 2008 Report Card to seven plus the District of Columbia in the 2011 Report Card. Along with the District of Columbia (100%), states receiving an A grade now include: Vermont (100%), Nebraska (93%), Maryland (90%), Minnesota (89%), Oregon (88%), Rhode Island (88%), and Washington (83%).

Fifty percent of states received a B grade. The top nine states with B grades, ranging from 75% to 80%, include: New Jersey (80%), Ohio (80%), Virginia (78%), South Dakota (78%), New Hampshire (77%), Michigan (76%), and Missouri, New York and North Carolina (each with 75%).

Does Your State Make the Grade?

Despite the rapid growth of palliative care teams in our nation's hospitals and improvement since the last Report Card, access to palliative care services in the United States must improve if we are to adequately care for our sickest patients. In 2008, our nation received an overall grade of C. In 2011, the country receives an overall grade of B. Seven states plus the District of Columbia now receive a grade of A, with more than 80% of hospitals reporting palliative care services. More than half of the 50 states receive a grade of B. Fewer than 25% of states now need significant improvement (C). Approximately 12% receive nonpassing grades of D or F (Table 1).

Where You Live Matters

“Geography is destiny,” as the Dartmouth Atlas researchers have often pointed out,² appears to hold true when speaking of access to hospitals offering palliative care. In the Northeast, 73% of hospitals with 50 or more beds report a palliative care team, compared to only 51% in the South. Among hospitals with fewer than 50 beds, your chances of having access to a palliative care team are extremely limited, particularly in the South, where only 14% of small hospitals (fewer than 50 beds) report having palliative care services.

Nationally, the prevalence of palliative care in large hospitals with 300 or more beds is 85%, ranging from 50% (Alabama and Delaware) to 100% in 19 states. The lowest prevalence rates of palliative care in large hospitals were found in Alabama (50%) and Delaware (50%). The highest rates in large hospitals were found in 19 states with 100% prevalence (see www.capc.org/reportcard).

The number of small hospitals (under 50 beds) varies widely by state. For example, four states (Connecticut, Delaware, New Jersey, and Rhode Island) and the District of Columbia do not report any hospitals of this size. The 2011 Report Card shows that the national prevalence rate for palliative care services in small hospitals is 22%. The lowest prevalence rates in small hospitals are found in Louisiana (0%), Mississippi (0%), and Alabama (4%). The highest prevalence rates for small hospitals are found in New Hampshire (62%) and Maine (58%).

Underserved Populations Have Less Access to Palliative Care

In addition to marked disparities in geographic availability, we observed low rates of access to palliative care in public and sole community provider hospitals. Public and sole community provider hospitals often serve as the only option for medical care for the 47 million Americans lacking health care coverage or living in geographically isolated communities. Therefore, our finding that the majority of these institutions continue to lack palliative care services speaks to a disparity in access to comprehensive care for America's most vulnerable patient populations. Notably:

• ➢ Only 54% of public hospitals provide their patients access to palliative care.

• ➢ Fewer than 40% of sole community provider hospitals offer their patients access to palliative care.

Lack of Board-Certified Palliative Medicine Physicians

Improving access to palliative care for America's patients and families requires a workforce highly trained in the fundamentals of palliative medicine. Today in the United States there are 2887 physicians board-certified in palliative medicine.

Prevalence of board-certified palliative care physicians varies across states. The highest rates are to be found in Hawaii (1 per 154 Medicare deaths), New Mexico (1 per 222 Medicare deaths), and Colorado (1 per 244 Medicare deaths). The lowest rates are in Mississippi (1 per 1698 Medicare deaths), Rhode Island (1 per 1267 Medicare deaths), Montana (1 per 1218 Medicare deaths), Delaware (1 per 1060 Medicare deaths), and South Dakota (1 per 1037 Medicare deaths).

The major findings in this report build on research first described by Goldsmith et al.1 The data in this report are obtained primarily from the American Hospital Association (AHA) Annual Survey Database^™ for fiscal year 2009. Additional data for the 2011 America's Care of Serious Illness were obtained from the American Board of Medical Specialties (ABMS), American Academy of Hospice and Palliative Medicine (AAHPM), National Board for Certification of Hospice and Palliative Nurses, and the Dartmouth Atlas. For more information, visit www.capc.org/reportcard.