Racial disparity in end-of-life hospitalizations among nursing home residents with dementia.
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ABSTRACT: Objective
Explore within and across nursing home (NH) racial disparities in end-of-life (EOL) hospitalizations for residents with Alzheimer's disease or related dementia (ADRD), and examine whether severe cognitive impairment influences these relationships.Design
Observational study merging, at the individual level, C2014-2017 national-level Minimum Data Set (MDS), Medicare Beneficiary Summary Files (MBSF), and Medicare Provider Analysis and Review (MedPAR). Nursing Home Compare (NHC) was also used.Setting
Long-stay residents who died in a NH or a hospital within 8 days of discharge.Participants
Analytical sample included 665,033 decedent residents with ADRD in 14,595 facilities.Main outcomes and measures
The outcome was hospitalization within 30 days of death. Key independent variables were race, severe cognitive impairment, and NH-level proportion of black residents. Other covariates included socio-demographics, dual eligibility, hospice enrollment, and chronic conditions. Facility-level characteristics were also included (e.g. profit status, staffing hours, etc.). We fit linear probability models with robust standard errors, fixed and random effects.Results
Compared to whites, black decedents had a significantly (p < 0.01) higher risk of EOL hospitalizations (7.88%). Among those with severe cognitive impairment, whites showed a lower risk of hospitalizations (6.04%). But EOL hospitalization risk among blacks with severe cognitive impairment was still significantly elevated (β = 0.0494; p < 0.01). A comparison of the base model with the fixed and random-effects models showed statistically significant hospitalization risk by decedent's race both within and across facilities.Conclusions and relevance
We found disparities between black and white residents with ADRD both within and across facilities. The within-facility disparities may be due to residents' preferences and/or NH practices that contribute to differential treatment. The across facility differences point to the overall quality of care disparities in homes with a higher prevalence of black residents. Persistence of such systemic disparities among the most vulnerable individuals is extremely troubling.
SUBMITTER: Temkin-Greener H
PROVIDER: S-EPMC8273114 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundEnd-of-life hospitalizations in nursing home residents are common, although they are often burdensome and potentially avoidable.AimWe aimed to summarize the existing evidence on end-of-life hospitalizations in nursing home residents.DesignSystematic review (PROSPERO registration number CRD42017072276).Data sourcesA systematic literature search was carried out in PubMed, CINAHL, and Scopus (date of search 9 April 2019). Studies were included if they reported proportions of in-hospital deaths or hospitalizations of nursing home residents in the last month of life. Two authors independently selected studies, extracted data, and assessed the quality of studies. Median with interquartile range was used to summarize proportions.ResultsA total of 35 studies were identified, more than half of which were from the United States (n = 18). While 29 studies reported in-hospital deaths, 12 studies examined hospitalizations during the last month of life. The proportion of in-hospital deaths varied markedly between 5.9% and 77.1%, with an overall median of 22.6% (interquartile range: 16.3%-29.5%). The proportion of residents being hospitalized during the last month of life ranged from 25.5% to 69.7%, and the median was 33.2% (interquartile range: 30.8%-38.4%). Most studies investigating the influence of age found that younger age was associated with a higher likelihood of end-of-life hospitalization. Four studies assessed trends over time, showing heterogeneous findings.ConclusionThere is a wide variation in end-of-life hospitalizations, even between studies from the same country. Overall, such hospitalizations are common among nursing home residents, which indicates that interventions tailored to each specific health care system are needed to improve end-of-life care.
| S-EPMC6899437 | biostudies-literature
Project description:BACKGROUND:Half of nursing home residents (NHR) suffer from dementia. End-of-life hospitalizations are often burdensome in residents with dementia. A systematic review was conducted to study the occurrence of hospitalizations at the end of life in NHR with dementia and to compare these figures to NHR without dementia. METHODS:A systematic literature search in MEDLINE, CINAHL and Scopus was conducted in May 2018. Studies were included if they reported proportions of in-hospital deaths or hospitalizations of NHR with dementia in the last month of life. Two authors independently selected studies, extracted data, and assessed quality of studies. RESULTS:Nine hundred forty-five citations were retrieved; 13 studies were included. Overall, 7 studies reported data on in-hospital death with proportions ranging between 0% in Canada and 53.3% in the UK. Studies reporting on the last 30 days of life (n = 8) varied between 8.0% in the Netherlands and 51.3% in Germany. Two studies each assessed the influence of age and sex. There seem to be fewer end-of-life hospitalizations in older age groups. The influence of sex is inconclusive. All but one study found that at the end of life residents with dementia were hospitalized less often than those without (n = 6). CONCLUSIONS:We found large variations in end-of-life hospitalizations of NHR with dementia, probably being explained by differences between countries. The influence of sex and age might differ when compared to residents without dementia. More studies should compare NHR with dementia to those without and assess the influence of sex and age. TRIAL REGISTRATION:PROSPERO registration number CRD42018104263 .
| S-EPMC6737675 | biostudies-literature
Project description:OBJECTIVES:To examine quality of life (QOL) in nursing home (NH) residents with advanced dementia and identify correlates of QOL near the end of life. DESIGN:Cross-sectional data derived from NH records, interviews with residents' surrogate decision-makers, QOL ratings by NH caregivers, and assessment of residents' cognitive function. SETTING:Three NHs in Maryland. PARTICIPANTS:A cohort of NH residents with dementia (n=119) who were receiving hospice or palliative care or met hospice criteria for dementia and their surrogates. MEASUREMENTS:QOL based on the proxy-rated Alzheimer' Disease-Related Quality of Life (ADRQL) scale administered to NH staff and validated against a single-item surrogate-rated measure of QOL, the Severe Impairment Rating Scale, to measure cognitive function and dichotomous indicators of neuropsychiatric symptoms (behavior problems, mood disorders, psychosis, delusions). RESULTS:Total ADRQL scores, ranging from 12.4 to 95.1 out of 100, were normally distributed and positively correlated (P<.001) with surrogate-rated QOL. Multiple regression analysis of ADRQL scores showed that residents with higher cognitive function (P<.001, 95% confidence interval (CI)=0.97-1.65) and those receiving pain medication (P=.006, 95% CI=3.30-19.59) had higher QOL, whereas residents with behavior problems (P=.01, 95% CI=-11.60 to -1.30) had lower QOL. CONCLUSION:The ADRQL is a valid indicator of QOL in NH residents with advanced dementia. QOL in this population may be improved near the end of life using appropriate assessment and treatment of pain and effective management of behavior problems.
| S-EPMC3057956 | biostudies-literature
Project description:ObjectiveUltrahigh therapy use has increased in SNFs without concomitant increases in residents' characteristics. It has been suggested that this trend may also have influenced the provision of high-intensity rehabilitation therapies to residents who are at the end of life (EOL). Motivated by lack of evidence, we examined therapy use and intensity among long-stay EOL residents.DesignAn observational study covering a time period 2012-2016.Setting and participantsNew York State nursing homes (N = 647) and their long-stay decedent residents (N = 55,691).MethodsData sources included Minimum Data Set assessments, vital statistics, Nursing Home Compare website, LTCfocus, and Area Health Resource File. Therapy intensity in the last month of life was the outcome measure. Individual-level covariates were used to adjust for health conditions. Facility-level covariates were the key independent variables of interest. Multinomial logistic regression models with facility random effects were estimated.ResultsOverall, 13.6% (n = 7600) of long-stay decedent residents had some therapy in the last month of life, 0% to 45% across facilities. Of those, almost 16% had very high/ultrahigh therapy intensity (>500 minutes) prior to death. Adjusting for individual-level covariates, decedents in the for-profit facilities had 18% higher risk of low/medium therapy [relative risk ratio (RRR) = 1.182, P < .001], and more than double the risk of high/ultrahigh therapy (RRR = 2.126, P < .001), compared to those with no therapy use in the last month of life. In facilities with higher physical therapy staffing, decedents had higher risk (RRR = 16.180, P = .002) of high/ultrahigh therapy, but not of low/medium therapy intensity. The use of high/ultrahigh therapy in this population has increased over time.Conclusions and relevanceThis is a first study to empirically demonstrate that facility characteristics are associated with the provision of therapy intensity to EOL residents. Findings suggest that facilities with a for-profit mission, and with higher staffing of therapists, may be more incentivized to maximize therapy use, even among the sickest of the residents.
| S-EPMC8491277 | biostudies-literature
Project description:BackgroundHealth care transitions in the last months of life can be burdensome and potentially of limited clinical benefit for patients with advanced cognitive and functional impairment.MethodsTo examine health care transitions among Medicare decedents with advanced cognitive and functional impairment who were nursing home residents 120 days before death, we linked nationwide data from the Medicare Minimum Data Set and claims files from 2000 through 2007. We defined patterns of transition as burdensome if they occurred in the last 3 days of life, if there was a lack of continuity in nursing homes after hospitalization in the last 90 days of life, or if there were multiple hospitalizations in the last 90 days of life. We also considered various factors explaining variation in these rates of burdensome transition. We examined whether there was an association between regional rates of burdensome transition and the likelihood of feeding-tube insertion, hospitalization in an intensive care unit (ICU) in the last month of life, the presence of a stage IV decubitus ulcer, and hospice enrollment in the last 3 days of life.ResultsAmong 474,829 nursing home decedents, 19.0% had at least one burdensome transition (range, 2.1% in Alaska to 37.5% in Louisiana). In adjusted analyses, blacks, Hispanics, and those without an advance directive were at increased risk. Nursing home residents in regions in the highest quintile of burdensome transitions (as compared with those in the lowest quintile) were significantly more likely to have a feeding tube (adjusted risk ratio, 3.38), have spent time in an ICU in the last month of life (adjusted risk ratio, 2.10), have a stage IV decubitus ulcer (adjusted risk ratio, 2.28), or have had a late enrollment in hospice (adjusted risk ratio, 1.17).ConclusionsBurdensome transitions are common, vary according to state, and are associated with markers of poor quality in end-of-life care.
| S-EPMC3236369 | biostudies-literature
Project description:ImportanceNursing home residents with advanced dementia have limited life expectancies yet are commonly subjected to burdensome interventions at the very end of life. Whether sex-specific differences in the receipt of these interventions exist and what levels of physical restraints and antibiotics are used in this terminal setting are unknown.ObjectiveTo evaluate the population-based frequency, factors, and sex differences in burdensome interventions and antibiotic therapy among nursing home residents with advanced dementia.Design, setting, and participantsThis population-based cohort study from Ontario, Canada, used linked administrative databases held at ICES, including the Continuing Care Resident Reporting System Long-Term Care database, which contains data from the Resident Assessment Instrument Minimum Data Set, version 2.0. Nursing home residents (n?=?27?243) with advanced dementia who died between June 1, 2010, and March 31, 2015, at 66 years or older were included in the analysis. Initial statistical analysis was completed in May 2017, and analytical revisions were conducted from November 2018 to January 2019.ExposureSex of the nursing home resident.Main outcomes and measuresBurdensome interventions (transitions of care, invasive procedures, and physical restraints) and antibiotic therapy in the last 30 days of life.ResultsThe final cohort included 27?243 nursing home residents with advanced dementia (19?363 [71.1%] women) who died between June 1, 2010, and March 31, 2015, at the median (interquartile range) age of 88 (83-92) years. In the last 30 days of life, burdensome interventions were common, especially among men: 5940 (21.8%) residents were hospitalized (3661 women [18.9%] vs 2279 men [28.9%]; P?<?.001), 2433 (8.9%) had an emergency department visit (1579 women [8.2%] vs 854 men [10.8%]; P?<?.001), and 3701 (13.6%) died in an acute care facility (2276 women [11.8%] vs 1425 men [18.1%]; P?<?.001). Invasive procedures were also common; 2673 residents (9.8%) were attended for life-threatening critical care (1672 women [8.6%] vs 1001 men [12.7%]; P?<?.001), and 210 (0.8%) received mechanical ventilation (113 women [0.6%] vs 97 men [1.2%]; P?<?.001). Among the 9844 residents (36.1%) who had a Resident Assessment Instrument Minimum Data Set, version 2.0, completed in the last 30 days of life, 2842 (28.9%) were physically restrained (2002 women [28.3%] vs 840 men [30.4%]; P?=?.005). More than one-third (9873 [36.2%]) of all residents received an antibiotic (6599 women [34.1%] vs 3264 men [41.4%]; P?<?.001). In multivariable models, men were more likely to have a transition of care (adjusted odds ratio, 1.41; 95% CI, 1.33-1.49; P?<?.001) and receive antibiotics (adjusted odds ratio, 1.33; 95% CI, 1.26-1.41; P?<?.001). Only 3309 residents (12.1%; 2382 women [12.3%] vs 927 men [11.8%]) saw a palliative care physician in the year before death, but those who did experienced greater than 50% lower odds of an end-of-life transition of care (adjusted odds ratio, 0.48; 95% CI, 0.43-0.54); P?<?.001) and greater than 25% lower odds of receiving antibiotics (adjusted odds ratio, 0.74; 95% CI, 0.68-0.81; P?<?.001).Conclusions and relevanceIn this study, many nursing home residents with advanced dementia, especially men, received burdensome interventions and antibiotics in their final days of life. These findings appear to emphasize the need for sex-specific analysis in dementia research as well as the expansion of palliative care and end-of-life antimicrobial stewardship in nursing homes.
| S-EPMC6704739 | biostudies-literature
Project description:BACKGROUND:Nursing homes are becoming more important for end-of-life care. Within the industrialised world, Germany is among the countries with the most end-of-life hospitalizations in nursing home residents. To improve end-of-life care, investigation in the status quo is required. The objective was to gain a better understanding of the perspectives of nursing home staff on the current situation of end-of-life care in Germany. METHODS:A cross-sectional study was conducted as a postal survey among a random sample of 1069 German nursing homes in 2019. The survey was primarily addressed to nursing staff management. Data was analyzed using descriptive statistics. Staff was asked to rate different items regarding common practices and potential deficits of end-of-life care on a 5-point-Likert-scale. Estimations of the proportions of in-hospital deaths, residents with advance directives (AD), cases in which documented ADs were ignored, and most important measures for improvement of end-of-life care were requested. RESULTS:486 (45.5%) questionnaires were returned, mostly by nursing staff managers (64.7%) and nursing home directors (29.9%). 64.4% of the respondents rated end-of-life care rather good, the remainder rated it as rather bad. The prevalence of in-hospital death was estimated by the respondents at 31.5% (SD: 19.9). Approximately a third suggested that residents receive hospital treatments too frequently. Respondents estimated that 45.9% (SD: 21.6) of the residents held ADs and that 28.4% (SD: 26.8) of available ADs are not being considered. Increased staffing, better qualification, closer involvement of general practitioners and better availability of palliative care concepts were the most important measures for improvement. CONCLUSIONS:Together with higher staffing, better availability and integration of palliative care concepts may well improve end-of-life care. Prerequisite for stronger ties between nursing home and palliative care is high-quality education of those involved in end-of-life care.
| S-EPMC6942381 | biostudies-literature
Project description:ObjectiveHealth disparities are pervasive in nursing homes (NHs), but disparities in NH end-of-life (EOL) care (ie, hospital transfers, place of death, hospice use, palliative care, advance care planning) have not been comprehensively synthesized. We aim to identify differences in NH EOL care for racial/ethnic minority residents.DesignA systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and registered in PROSPERO (CRD42020181792).Setting and participantsOlder NH residents who were terminally ill or approaching the EOL, including racial/ethnic minority NH residents.MethodsThree electronic databases were searched from 2010 to May 2020. Quality was assessed using the Newcastle-Ottawa Scale.ResultsEighteen articles were included, most (n = 16) were good quality and most (n = 15) used data through 2010. Studies varied in definitions and grouping of racial/ethnic minority residents. Four outcomes were identified: advance care planning (n = 10), hospice (n = 8), EOL hospitalizations (n = 6), and pain management (n = 1). Differences in EOL care were most apparent among NHs with higher proportions of Black residents. Racial/ethnic minority residents were less likely to complete advance directives. Although hospice use was mixed, Black residents were consistently less likely to use hospice before death. Hispanic and Black residents were more likely to experience an EOL hospitalization compared with non-Hispanic White residents. Racial/ethnic minority residents experienced worse pain and symptom management at the EOL; however, no articles studied specifics of palliative care (eg, spiritual care).Conclusions and implicationsThis review identified NH health disparities in advance care planning, EOL hospitalizations, and pain management for racial/ethnic minority residents. Research is needed that uses recent data, reflective of current NH demographic trends. To help reduce EOL disparities, language services and cultural competency training for staff should be available in NHs with higher proportions of racial/ethnic minorities.
| S-EPMC8128037 | biostudies-literature
Project description:Background/objectivesStudies show that in nursing homes (NHs), the prevalence of moderate-to-severe obesity has doubled in the last decade and continues to increase. Obese residents are often complex and costly, and this increase in prevalence has come at a time when NHs struggle to decrease hospitalizations, particularly those that are potentially avoidable. This study examined the association between obesity and hospitalizations.DesignWe linked 2011-2014 national data using Medicare NH assessments, hospital claims, and the NH Compare.Setting and participantsIndividuals aged ≥65 years, newly admitted to NHs, who became long-term residents between July 1, 2011 and March 26, 2014. The analytical sample included 490,086 residents.MethodsNH-originating hospitalization was the outcome; a categorical variable defined as no hospitalization, potentially avoidable hospitalization (PAH), and other hospitalization (non-PAH). The main independent variable was body mass index (BMI) defined as normal weight (30 >BMI ≥18.5 kg/m2), mildly obese (35 >BMI ≥30 kg/m2), or moderately-to-severely obese (BMI ≥35 kg/m2). Covariates included individual and NH characteristics. Multinomial models with NH random effects and state dummies were estimated.ResultsAfter adjusting for individual level covariates, the risk of non-PAH for the mildly and moderate/severely obese was not different from normal weight residents. But the risk of PAH remained significantly higher for the moderate/severely obese (relative risk ratio = 1.055; 95% confidence interval 1.018, 1.094). Several NH-level factors also influenced hospitalization risk.Conclusions and implicationsObese residents are more likely to experience PAH but not non-PAH. Efforts to improve care for these residents may need to broadly consider the ability of NHs to commit additional resources to fully integrate care for this growing segment of the population.
| S-EPMC7483884 | biostudies-literature
Project description:BackgroundThis study examined factors associated with potentially burdensome end-of-life (EOL) transitions between care settings among older adults with advanced cancer in nursing homes (NHs).MethodsA retrospective analysis of deceased older NH residents with poor-prognosis solid tumors was conducted with Medicare claims and the Minimum Data Set. A potentially burdensome transition was defined as 2 or more hospitalizations or an intensive care unit admission in the last 90 days of life.ResultsAmong 34,670 subjects, many had moderate to severe cognitive impairment (53.8%), full dependence in activities of daily living (ADLs; 66.5%), and comorbidities such as congestive heart failure (CHF; 29.3%) and chronic obstructive pulmonary disease (34.1%). Only 56.3% of the patients used hospice at any time in the 90 days before death; 36.0% of the patients experienced a potentially burdensome EOL transition, and this was higher among patients who did not receive hospice (45.4% vs 28.7%; P < .01). In multivariable analyses, full dependence in ADLs (odds ratio [OR], 1.70; P < .01), CHF (OR, 1.48; P < .01), and chronic obstructive pulmonary disease (OR, 1.28; P < .01) were associated with a higher risk of burdensome EOL transitions. Those with do-not-resuscitate directives (OR, 0.60; P < .01) and impaired cognition (OR, 0.89; P < .01) had lower odds of burdensome EOL transitions.ConclusionsNH residents with advanced cancer have substantial comorbidities and functional impairment, yet more than a third experience potentially burdensome EOL transitions. These findings help to identify a population at risk for poor EOL outcomes in order to target interventions, and they point to the importance of advanced care planning in this population.
| S-EPMC7306135 | biostudies-literature