End-of-life hospitalization for African American and non-Latino white nursing home residents: variation by race and a facility's racial composition.
ABSTRACT Hospitalization of nursing home residents at the end of life is common, more so among African Americans. Whether a nursing home's racial mix is associated with hospitalization is unknown.
This study examined the association between race, a nursing home's racial mix, and end-of-life hospitalization.
This was a retrospective cohort study.
Studied were nursing home residents in New York (n = 14,159) and Mississippi (n = 1481) who died in 1995-1996 and had a minimum data set (MDS) assessment within 120 days of death.
The outcome measure was the odds of hospitalization in the last 90 days of life. A variable reflecting a nursing home's proportion of African American residents (in 1995-1996) represented a nursing home's racial mix.
Forty-six percent of African Americans and 32% of whites were hospitalized in the last 90 days of life. After controlling for demographics, diagnoses, function, patient preferences (do-not-resuscitate [DNR]), and facility resources, nursing home residents in facilities having higher proportions of African American residents had greater odds of hospitalization (adjusted odds ratio [AOR] 1.14; 95% confidence interval [CI] 1.10, 1.18 in New York and AOR 1.35; 95% CI 1.24, 1.46 in Mississippi). Age and frailty interacted with race; older African Americans had a 16% greater likelihood (95% CI 1.08, 1.24) of hospitalization, and African Americans with more functional limitations had a 37% (95% CI 1.24, 1.51) greater likelihood of hospitalization than did comparable whites.
It appears higher end-of-life hospitalization rates for African American residents are attributable to the facilities where most reside, and to differential hospitalization of older or more functional limited residents.
[Show abstract] [Hide abstract]
ABSTRACT: Older adults are vulnerable to experiencing physiologic changes that may permanently decrease functional abilities when transferring from the nursing home (NH) to the acute care setting. Making the right decision about who and when to transfer from the nursing home (NH) to acute care is critical for optimizing quality care. The specific aims of this study were to identify the common signs and symptoms exhibited by NH residents at the time of transfer to acute care and to identify strategies used to prevent transfer of NH residents. Using survey methodology, this descriptive study found change in level of consciousness, chest pressure/tightness, shortness of breath, decreased oxygenation, and muscle or bone pain were the highest ranked signs/symptoms requiring action. Actions to prevent transfer focused on stabilizing resident conditions and included hydration, oxygen, antibiotics, medications, symptom management, and providing additional physical assistance. When transfer was warranted, actions concentrated on the practical tasks of getting the residents transferred.Geriatric Nursing 07/2014; 35(4). DOI:10.1016/j.gerinurse.2014.06.007 · 0.92 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: Abstract Purpose: A knowledge transfer program was carried out to improve knowledge in end-of-life care staff at all levels in residential care homes for the elderly, using a model similar to that developed for a non-acute care hospital setting. Methods: The program consisted of a series of seminars and on-site sharing sessions held in the hospital providing outreach support to residential care homes for the elderly (RCHEs), as well as case discussions in the RCHEs. Evaluation was carried out using a knowledge assessment questionnaire before and after the initiative, as well as recording RCHE staff feedback and in-depth interviews with selected residents and their family members. Results: Knowledge gaps among RCHE staff existed in the areas of mortality relating to chronic diseases, pain and use of analgesics, feeding tubes, dysphagia, sputum management, and attitudes towards end-of-life care issues, which improved after the program. From the qualitative study, RCHE staff highlighted knowledge and service gaps, issues relating to use of feeding tubes and refusal to eat, lack of confidence in managing the dying process, application of Advance Care Plan (ACP) in the RCHE setting, and the need for training in these areas. Residents and family members highlighted the preference for death over suffering, planning for death, misconceptions about life-sustaining treatments and the advance directive (AD) document, and service gaps in advance care planning. Conclusion: Considerable knowledge and service gaps exist among staff and residents of RCHEs, which can be improved by the hospital geriatric team providing services to RCHEs.Journal of palliative medicine 09/2013; 16(10). DOI:10.1089/jpm.2013.0190 · 1.84 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: To examine the incidence of, variations in, and costs of potentially avoidable hospitalizations (PAHs) of nursing home (NH) residents at the end of life and to identify the association between NH characteristics and a facility-level quality measure (QM) for PAH. Retrospective. Hospitalizations originating from NHs. Long-term care NH residents who died in 2007. A risk-adjusted QM was constructed for PAH. A Poisson regression model was used to predict the count of PAH given residents' risk factors. For each facility, the QM was defined as the difference between the observed facility-specific rate (per 1,000 person-years) of PAH (O) and the expected risk-adjusted rate (E). A logistic regression model with state fixed-effects was then fit to examine the association between facility characteristics and the likelihood of having higher-than-expected rates of PAH (O-E > 0). QM values greater than 0 indicate worse-than-average quality. Almost 50% of hospital admissions for NH residents in their last year of life were for potentially avoidable conditions, costing Medicare $1 billion. Five conditions were responsible for more than 80% of PAHs. PAH QM across facilities showed significant variation (mean 12.0 ± 142.3 per 1,000 person-years, range -399.48 to 398.09 per 1,000 person-years). Chain and hospital-based facilities were more likely to exhibit better performance (O-E < 0). Facilities with higher nursing staffing were more likely to have better performance, as were facilities with higher skilled staff ratio, those with nurse practitioners or physician assistants, and those with on-site X-ray services. Variations in facility-level PAHs suggest that a potential for reducing hospital admissions for these conditions may exist. Presence of modifiable facility characteristics associated with PAH performance could help us formulate interventions and policies for reducing PAHs at the end of life.Journal of the American Geriatrics Society 11/2013; 61(11):1900-8. DOI:10.1111/jgs.12517 · 4.22 Impact Factor