End-of-Life Transitions among Nursing Home Residents with Cognitive Issues
Among nursing home residents with cognitive impairment, burdensome transitions between the nursing home and the hospital or hospice during the last months of life were common, varied according to state, and were associated with a poor quality of care. Health care transitions, such as the hospitaliza...
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| Vydané v: | The New England journal of medicine Ročník 365; číslo 13; s. 1212 - 1221 |
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| Hlavní autori: | , , , , , , |
| Médium: | Journal Article |
| Jazyk: | English |
| Vydavateľské údaje: |
Waltham, MA
Massachusetts Medical Society
29.09.2011
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| Predmet: | |
| ISSN: | 0028-4793, 1533-4406, 1533-4406 |
| On-line prístup: | Získať plný text |
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| Abstract | Among nursing home residents with cognitive impairment, burdensome transitions between the nursing home and the hospital or hospice during the last months of life were common, varied according to state, and were associated with a poor quality of care.
Health care transitions, such as the hospitalization of nursing home residents, have the potential for fragmentation of care, changes in the management of chronic diseases, duplication of diagnostic workups, and medical errors.
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Few previous reports have described health care transitions among nursing home residents who had advanced cognitive impairment. These patients and their family members are especially vulnerable to the adverse consequences resulting from transitions, particularly during end-of-life care. Pertinent sources of distress include the trauma of the physical transfer, increased confusion because of unfamiliar settings and providers, inadequate ability to address the patient's special needs (e.g., assistance with . . . |
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| AbstractList | Among nursing home residents with cognitive impairment, burdensome transitions between the nursing home and the hospital or hospice during the last months of life were common, varied according to state, and were associated with a poor quality of care.
Health care transitions, such as the hospitalization of nursing home residents, have the potential for fragmentation of care, changes in the management of chronic diseases, duplication of diagnostic workups, and medical errors.
1
–
7
Few previous reports have described health care transitions among nursing home residents who had advanced cognitive impairment. These patients and their family members are especially vulnerable to the adverse consequences resulting from transitions, particularly during end-of-life care. Pertinent sources of distress include the trauma of the physical transfer, increased confusion because of unfamiliar settings and providers, inadequate ability to address the patient's special needs (e.g., assistance with . . . Background: Health 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. Methods: To 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. Results: Among 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). Conclusions: Burdensome transitions are common, vary according to state, and are associated with markers of poor quality in end-of-life care. 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. (Funded by the National Institute on Aging.) Health 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. To 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. Among 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). Burdensome transitions are common, vary according to state, and are associated with markers of poor quality in end-of-life care. Health 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.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.To 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.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.Among 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).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).Burdensome transitions are common, vary according to state, and are associated with markers of poor quality in end-of-life care.CONCLUSIONSBurdensome transitions are common, vary according to state, and are associated with markers of poor quality in end-of-life care. |
| Author | Mitchell, Susan L Gozalo, Pedro Skinner, Jon Mor, Vincent Bynum, Julie Tyler, Denise Teno, Joan M |
| Author_xml | – sequence: 1 givenname: Pedro surname: Gozalo fullname: Gozalo, Pedro – sequence: 2 givenname: Joan M surname: Teno fullname: Teno, Joan M – sequence: 3 givenname: Susan L surname: Mitchell fullname: Mitchell, Susan L – sequence: 4 givenname: Jon surname: Skinner fullname: Skinner, Jon – sequence: 5 givenname: Julie surname: Bynum fullname: Bynum, Julie – sequence: 6 givenname: Denise surname: Tyler fullname: Tyler, Denise – sequence: 7 givenname: Vincent surname: Mor fullname: Mor, Vincent |
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| Snippet | Among nursing home residents with cognitive impairment, burdensome transitions between the nursing home and the hospital or hospice during the last months of... Health care transitions in the last months of life can be burdensome and potentially of limited clinical benefit for patients with advanced cognitive and... BackgroundHealth care transitions in the last months of life can be burdensome and potentially of limited clinical benefit for patients with advanced cognitive... Background: Health care transitions in the last months of life can be burdensome and potentially of limited clinical benefit for patients with advanced... |
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| SubjectTerms | Activities of daily living Advance directives Aged Aged, 80 and over Aging Biological and medical sciences Cardiovascular disease Cognition Disorders - therapy Cognitive ability Continuity of Patient Care Dementia Ethics Feeding Female General aspects Hospitalization Hospitalization - statistics & numerical data Humans Male Medical sciences Medicare Nursing Homes Palliative care Patient Transfer - statistics & numerical data Patients Pneumonia Pressure ulcers Public health. Hygiene Public health. Hygiene-occupational medicine Quality Quality of Health Care Sociodemographics Teaching. Deontology. Ethics. Legislation Terminal Care - standards Terminal Care - statistics & numerical data United States |
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| Title | End-of-Life Transitions among Nursing Home Residents with Cognitive Issues |
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