Rural-Urban Differences in End-of-Life Nursing Home Care: Facility and Environmental Factors
ABSTRACT This study examines urban-rural differences in end-of-life (EOL) quality of care provided to nursing home (NH) residents.
We constructed 3 risk-adjusted EOL quality measures (QMs) for long-term decedent residents: in-hospital death, hospice referral before death, and presence of severe pain. We used CY2005-2007 100% Minimum Data Set, Medicare beneficiary file, and inpatient and hospice claims. Logistic regression models were estimated to predict the probability of each outcome conditional on decedents' risk factors. For each facility, QMs were calculated as the difference between the actual and the expected risk-adjusted outcome rates. We fit multivariate linear regression models, with fixed state effects, for each QM to assess the association with urban-rural location.
We found urban-rural differences for in-hospital death and hospice QMs, but not for pain. Compared with NHs located in urban areas, facilities in smaller towns and in isolated rural areas have significantly (p < .001) worse EOL quality for in-hospital death and hospice use. Whereas the differences in these QMs are statistically significant between facilities located in large versus small towns, they are not statistically significant between facilities located in small towns and isolated rural areas.
This study provides empirical evidence for urban-rural differences in EOL quality of care using a national sample of NHs. Identifying differences is a necessary first step toward improving care for dying NH residents and for bridging the urban-rural gap.
[Show abstract] [Hide abstract]
ABSTRACT: OBJECTIVES: To describe the longitudinal patterns and the within- and between-facility differences in hospice use and in-hospital deaths between long-term nursing home (NH) residents with and without dementia. DESIGN: Retrospective analyses of secondary data sets from 2003 to 2007. SETTING: NHs in the United States. PARTICIPANTS: A total of 1,261,726 decedents in 16,347 NHs were included in 2003 to 2007 trend analysis and 236,619 decedents in 15,098 NHs in 2007 were included in the within- and between-facility analyses. MEASUREMENTS: Hospice use in the last 100 days of life and in-hospital deaths were outcome measures. Dementia was defined as having a diagnosis of Alzheimer's disease or other dementia based on Minimum Data Set (MDS) health assessments. RESULTS: Overall hospice use increased from 25.6% in 2003 to 35.7% in 2007. During this time, hospice use for decedents with dementia increased from 25.1% to 36.5%, compared with an increase from 26.5% to 34.4% for decedents without dementia. The rate of in-hospital deaths remained virtually unchanged. Within the same facility, decedents with dementia were significantly more likely to use hospice (odds ratio (OR) = 1.07, 95% confidence interval (CI) = 1.04-1.11) and less likely to die in a hospital (OR = 0.76, 95% CI = 0.74-0.78). Decedents in NHs with higher dementia prevalence, regardless of individual dementia status, were more likely to use hospice (OR = 1.67, 95% CI = 1.22-2.27). CONCLUSION: NHs appear to provide less-aggressive end-of-life care to decedents with dementia than to those without. Although significantly more residents with dementia now receive hospice care at the end of life, the quality evaluation and monitoring of hospice programs have not been systematically conducted, and additional research in this area is warranted.Journal of the American Geriatrics Society 06/2013; 61(7). DOI:10.1111/jgs.12330 · 4.22 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: Objectives: Hospice care provided to nursing home (NH) residents has been shown to improve the quality of end-of-life (EOL) care. However, hospice utilization in NHs is typically low. This study examined the relationship between facility self-reported EOL practices and residents' hospice use and length of stay. Design:The study was based on a retrospective cohort of NH residents. Medicare hospice claims, Minimum Data Set, Online Survey, Certification, and Reporting system and the Area Resource File were linked with a survey of directors of nursing (DON) regarding institutional EOL practice patterns (EOLC Survey).Setting and Participants: In total, 4,540 long-term-care residents who died in 2007 in 290 facilities which participated in the EOLC Survey were included in this study. Measurements: We measured NHs' tendency to offer hospice to residents and to initiate aggressive treatments (hospital transfers and feeding tubes) for EOL residents based on DON's responses to survey items. Residents' hospice utilization was determined using Medicare hospice claims. RESULTS: The prevalence of hospice use was 18%. The average length of stay was 93 days. After controlling for individual risk factors, facilities' self-reported practice measures associated with residents' likelihood of using hospice were tendency to offer hospice (p = .048) and tendency to hospitalize (p = .002). Residents in NHs reporting higher tendency to hospitalize tended to enroll in hospice closer to death.Conclusion:Residents' hospice utilization is not only associated with individual and facility characteristics but also with NHs' self-reported EOL care practices. Potential interventions to effect greater use of hospice may need to focus on facility-level care processes and practices.The Gerontologist 12/2012; 53(5). DOI:10.1093/geront/gns153 · 2.48 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: Background Although previous research has documented rural disparities in hospice use, limited data exist on the roles of geographic access in different types of end-of-life indicators among cancer survivors.Methods Medicare claims data were used to identify beneficiaries with colorectal cancer who died in 2008 (N = 34,975). We evaluated rural-urban differences in ER visits 90 days before death, inpatient hospital admissions ≤90 days before death, intensive care unit (ICU) use ≤90 days before death, hospice care use at any time, and hospice enrollment <3 days before death.ResultsAbout 60% of beneficiaries in rural areas lived in counties with the 2 lowest socioecomonic levels compared to only 5.3% of beneficiaries in metropolitan areas. After adjusting for demographic factors and comorbidities, beneficiaries in rural counties had a lower number of ICU days (RR = 0.65) and were less likely to ever use hospice (OR = 0.78) compared to those in metropolitan counties. Beneficiaries from racial/ethnic minority groups, those with lower socioeconomic status, and those with a higher comorbidity index were less likely to ever use hospice but they tended to use ER, inpatient care, and ICU.Conclusions Evidence for disparities due to geographic access and socioeconomic factors warrant increased efforts to remove systemic and structural barriers. Future research should focus on exploring and evaluating potential policy and practice interventions to improve the quality of life among elderly cancer survivors living in rural communities and those from socioeconomically disadvantaged backgrounds.The Journal of Rural Health 05/2014; DOI:10.1111/jrh.12074 · 1.77 Impact Factor