Abstract
Objectives
Nursing homes (NHs) collaboration with hospices appears to improve end-of-life (EOL)
care among dying NH residents. However, the potential benefits of NH-hospice collaboration
may vary with the patterns of this collaboration. This study examines the relationship
between the attributes of NH-hospice collaboration, especially the exclusivity of
NH-hospice collaboration (ie, the number of hospice providers in a NH), and EOL hospitalizations
among dying NH residents.
Design
This national retrospective cohort study linked 2000-2009 NH assessments (ie, the
Minimum Data Set 2.0) and Medicare data. A linear probability model with facility
fixed-effects was estimated to examine the relationship between EOL hospitalization
and the attributes of NH-hospice collaborations, adjusting for individual and facility
characteristics. We also performed a set of sensitivity analyses, including stratified
analyses by volume of hospice services in a NH and stratified analyses by rural vs
urban NH locations.
Settings
All Medicare and/or Medicaid certified US NHs with at least 8 years of data and at
least 30 beds.
Participants
NH decedents resided in Medicare and/or Medicaid certified NHs in the US between 2000
and 2009. We restricted the analyses to those continuously enrolled in Medicare fee-for-service
in the last 6 months of life and those who were in NHs for the last 30 days of life.
In total, we identified 2,954,276 NH decedents over the study period.
Measurements
The outcome variable was measured as dichotomous, indicating whether a dying NH resident
was hospitalized in the last 30 days of life. The attributes of NH-hospice collaboration
were measured by the volume of hospice services (defined as the ratio of number of
hospice days to the total NH days per NH per calendar year) and the number of hospice
providers in a NH (defined as the number of unique hospice providers in a NH per year).
We categorized NHs into groups based on the number of hospice providers (1, 2 or 3,
and ≥4) in the NH, and conducted sensitivity analysis using a different categorization
(1, 2, and 3+ hospice providers).
Results
The pattern of NH-hospice collaboration changed significantly over years; the average
number of hospices in a NH increased from 1.4 in 2000 to 3.2 in 2009. The volume of
NH-hospice collaboration also increased substantially. The multivariate regression
analyses indicated that having more hospice providers in the NH was not associated
with lower risks of EOL hospitalizations. After accounting for individual and facility
characteristics, increasing hospice providers from 1 to at least 4 was associated
with an overall 1 percentage point increase in the likelihood of EOL hospitalizations
among dying residents (P < .01), and such relationship remained in NHs with moderate or high volume NHs in
the stratified analyses. Stratified analysis by rural vs urban NHs suggested that
the relationship between the number of hospice providers and EOL hospitalizations
was mainly in urban NHs.
Conclusions
More hospice providers in the NH was not associated with lower EOL hospitalizations,
especially among NHs with relatively high volume of hospice services.
Keywords
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Article info
Publication history
Published online: November 28, 2017
Footnotes
This work is funded by the National Institute on Aging Grant 1R03AG042648-01A1 for supporting this work.
The authors declare no conflicts of interest.
Identification
Copyright
© 2017 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
