Editor—Wennberg et al hypothesise that marked variation in use of healthcare resources at the end of life may be explained largely by variations in the supply of doctors and beds.1 Although this may play an important part, additional explanations are needed.
For example, why does such a large difference exist between New York University Medical Center and Mount Sinai Hospital in the number of intensive care days per decedent if the centres exist in the same city? One clue may be that many of the hospitals that have low numbers of intensive care days per decedent, such as Mount Sinai, University of California San Francisco, and Massachusetts General Hospital, also have active palliative care services with leaders in their field, such as Diane Meier, Steven Pantilat, and Andrew Billings, respectively. Informal social networks are important means by which these palliative care services may have far reaching impacts on the culture of the institutions in which they exist.2
Figure 1.
In other words, the manner in which doctors learn, and from whom and what they learn, may be an important means of understanding the results of Wennberg et al.
Competing interests: None declared.
References
- 1.Wennberg JE, Fisher ES, Stukel TA, Skinner JS, Sharp SM, Bronner KK. Use of hospitals, physician visits, and hospice care during the last six months of life among cohorts loyal to highly respected hospitals in the United States. BMJ 2004;328: 607. (13 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Laumann E, Knoke D. Social network theory. In: Lindenberg S, Coleman J, Nowak S, eds. Approaches to social theory. New York: Russell Sage Foundation, 1986: 83-109.