Abstract
Objectives
Nursing homes (NHs) are critical end-of-life (EOL) care settings for 70% of Americans
dying with Alzheimer's disease/related dementias (ADRD). Whether EOL care/outcomes
vary by NH/market characteristics for this population is unknown but essential information
for improving NH EOL care/outcomes. Our objectives were to examine variations in EOL
care/outcomes among decedents with ADRD and identify associations with NH/market characteristics.
Design
Cross-sectional.
Outcomes
Place-of-death (hospital/NH), presence of pressure ulcers, potentially avoidable hospitalizations
(PAHs), and hospice use at EOL. Key covariates were ownership, staffing, presence
of Alzheimer's units, and market competition.
Setting and Participants
Long-stay NH residents with ADRD, age 65 + years of age, who died in 2017 (N = 191,435;
14,618 NHs) in NHs or hospitals shortly after NH discharge.
Methods
National Medicare claims, Minimum Data Set, public datasets. Descriptive analyses
and multivariable logistic regressions.
Results
As ADRD severity increased, adjusted rates of in-hospital deaths and PAHs decreased
(17.0% to 6.3%; 11.2% to 7.0%); adjusted rates of dying with pressure ulcers and hospice
use increased (8.2% to 13.5%; 24.5% to 40.7%). Decedents with moderate and severe
ADRD had 16% and 13% higher likelihoods of in-hospital deaths in for-profit NHs. In
NHs with Alzheimer's units, likelihoods of in-hospital deaths, dying with pressure
ulcers, and PAHs were significantly lower. As ADRD severity increased, higher licensed
nurse staffing was associated with 14%‒27% lower likelihoods of PAHs. Increased NH
market competition was associated with higher likelihood of hospice use, and lower
likelihood of in-hospital deaths among decedents with moderate ADRD.
Conclusions and Implications
Decedents with ADRD in NHs that were nonprofit, had Alzheimer's units, higher licensed
nurse staffing, and in more competitive markets, had better EOL care/outcomes. Modifications
to state Medicaid NH payments may promote better EOL care/outcomes for this population.
Future research to understand NH care practices associated with presence of Alzheimer's
units is warranted to identify mechanisms possibly promoting higher-quality EOL care.
Keywords
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References
- U.S. burden of Alzheimer's disease, related dementias to double by 2060.(Available at:)https://www.cdc.gov/media/releases/2018/p0920-alzheimers-burden-double-2060.htmlDate: 2018Date accessed: September 25, 2018
- Quality of end-of-life care of long-term nursing home residents with and without dementia.J Am Ger Soc. 2013; 61: 1066-1073
- Hospital and nursing home use in the last three months of life.J Aging Health. 1996; 8: 307-319
- Palliative care for patients with dementia in long-term care.Clin Geriatr M. 2011; 27: 153-170
- The clinical course of advanced dementia.N Engl J Med. 2009; 361: 1529-1538
- Hospice care for persons with dementia: The growth of access in US nursing homes.Am J Alzheimer's Dis Other Dement. 2010; 25: 666-673
- Hospitalizations of nursing home residents in the last year of life: Nursing home characteristics and variation in potentially avoidable hospitalizations.J Am Ger Soc. 2013; 61: 1900-1908
- End-of-life quality-of-care measures for nursing homes: Place of death and hospice.J Palliat Med. 2012; 15: 438-446
- Prototype end-of-life quality measures based on MDS 3 Data.Med Care. 2016; 54: 1024-1032
- Cost drivers for dually eligible beneficiaries: Potentially avoidable hospitalizations from nursing facility, skilled nursing facility, and home and community-based services waiver programs (CMS Contract HHSM-500-2005-00029I).RTI International, Waltham, MA2010
- Clinical and organizational factors associated with feeding tube use among nursing home residents with advanced cognitive impairment.JAMA. 2003; 290: 73-80
- Measuring end-of-life care processes in nursing homes.Gerontologist. 2009; 49: 803-815
- Decisions to transfer nursing home residents to emergency departments: A scoping review of contributing factors and staff perspectives.J Am Med Dir Assoc. 2016; 17: 994-1005
- The staffing-outcomes relationship in nursing homes.Health Serv Res. 2008; 43: 1025-1042
- Revisiting the relationship between nurse staffing and quality of care in nursing homes: An instrumental variables approach.J Health Econ. 2014; 37: 13-24
- Relationship of nursing home staffing to quality of care.Health Serv Res. 2004; 39: 225-250
- Long-term care market competition and nursing home dementia special care units.Med Care. 2007; 45: 739-745
- Does information matter? Competition, quality, and the impact of nursing home report cards.Health Serv Res. 2011; 46: 1698-1719
- The quality of advanced dementia care in the nursing home: The role of special care units.Med Care. 2012; 50: 856-862
- The impact of dementia special care units on quality of care: An instrumental variables analysis.Health Serv Res. 2018; 53: 3657-3679
- Does the presence of a dementia special care unit improve nursing home quality?.J Aging Health. 2008; 20: 837-854
- The effect of Medicaid nursing home reimbursement policy on Medicare hospice use in nursing homes.Med Care. 2011; 49: 797-802
- Medicaid reimbursement and the quality of nursing home care.Health Econ. 2001; 20: 549-569
- Medicaid bed-hold policy and Medicare skilled nursing facility rehospitalizations.Health Serv Res. 2010; 45: 1963-1980
- Intended and unintended consequences of minimum staffing standards for nursing homes.Health Econ. 2015; 24: 822-839
- Staffing ratios and quality: An analysis of minimum direct care staffing requirements for nursing homes.Health Serv Res. 2011; 46: 1495-1516
- Medicaid nursing facility payment policy.(Available at:)https://www.macpac.gov/publication/medicaid-nursing-facility-payment-policy/Date: 2019Date accessed: October 11, 2018
- Site of death among nursing home residents in the United States: Changing patterns, 2003‒2007.J Am Med Dir Assoc. 2013; 14: 741-748
- ResDAC. MedPAR..(Available at:)
- Master Beneficiary summary file (MBSF) base.(Available at:)
- Long Term care minimum data set (MDS) 3.0.(Available at:)
- Nursing home Compare data archive: 2017 data.(Available at:)https://data.medicare.gov/data/archives/nursing-home-compareDate: 2018Date accessed: October 12, 2018
Long-term care: Facts on care in the US. Shaping Long Term Care in America Project at Brown University funded in part by the National Institute on Aging (1P01AG027296). Available at: http://ltcfocus.org/1/about-us. Accessed October 12, 2018.
- Area Health Resources Files.2018
- States' Medicaid fee-for-service nursing facility payment policies.(Available at:)https://www.macpac.gov/publication/nursing-facilty-payment-policies/Date: 2019Date accessed: February 13, 2020
- A Report on Shortfalls in Medicaid Funding for Nursing Center Care.2016
- Nursing home staffing standards in state statutes and regulations.University of California, San Francisco, CA2010
- Influence of hospice on nursing home residents with advanced dementia who received Medicare-skilled nursing facility care near the end of life.J Am Ger Soc. 2012; 60: 2035-2041
- The minimum data set 3.0 cognitive function scale.Med Care. 2017; 55: e68-e72
- Nursing home work environment and the risk of pressure ulcers and incontinence.Health Serv Res. 2012; 47: 1179-1200
- Validation of the Minimum Data Set in identifying hospitalization events and payment source.J Am Med Dir Assoc. 2011; 12: 38-43
- The aggressive behavior scale: A new scale to measure aggression based on the minimum data set.J Am Ger Soc. 2008; 56: 2298-2303
- Scaling ADLs within the MDS.J Gerontol A Biol Sci Med Sci. 1999; 54: M546-M553
- Nursing home-hospice collaboration and end-of-life hospitalizations among dying nursing home residents.J Am Med Dir Assoc. 2018; 19: 439-443
- Special care units for dementia individuals with behavioural problems.Cochrane Database Syst Rev. 2009; 4: Cd006470
- Racial differences in dementia care among nursing home residents.J Aging Health. 2012; 24: 711-731
- Dying with advanced dementia in the nursing home.Arch Intern Med. 2004; 164: 321-326
- Organizational and environmental correlates of the adoption of a focus strategy in U.S. hospices.Health Care Manage Rev. 2015; 40: 148-158
- Small area variations in health care delivery.Science. 1973; 182: 1102-1108
Article info
Publication history
Published online: July 28, 2020
Footnotes
This work was supported by the Agency for Healthcare Research and Quality (Grant R01HS024923).
The authors declare no conflicts of interest.
Identification
Copyright
© 2020 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
