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
Hlavní autori: Gozalo, Pedro, Teno, Joan M, Mitchell, Susan L, Skinner, Jon, Bynum, Julie, Tyler, Denise, Mor, Vincent
Médium: Journal Article
Jazyk:English
Vydavateľské údaje: Waltham, MA Massachusetts Medical Society 29.09.2011
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ISSN:0028-4793, 1533-4406, 1533-4406
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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. 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 . . .
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
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  givenname: Susan L
  surname: Mitchell
  fullname: Mitchell, Susan L
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  surname: Skinner
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  fullname: Bynum, Julie
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  givenname: Denise
  surname: Tyler
  fullname: Tyler, Denise
– sequence: 7
  givenname: Vincent
  surname: Mor
  fullname: Mor, Vincent
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Issue 13
Keywords Medicine
Ethics
Long stay
Nursing home for the aged
Transition
Resident
Cognition
End of life
Homes for the aged
Nursing home
Language English
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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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StartPage 1212
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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