Change in End-of-Life Care for Medicare Beneficiaries Site of Death, Place of Care, and Health Care Transitions in 2000, 2005, and 2009
Warren Alpert Medical School of Brown University, 121 S Main St, Providence, RI 02912, USA.JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 02/2013; 309(5):470-7. DOI: 10.1001/jama.2012.207624
Importance A recent Centers for Disease Control and Prevention report found that more persons die at home. This has been cited as evidence that persons dying in the United States are using more supportive care. Objective To describe changes in site of death, place of care, and health care transitions between 2000, 2005, and 2009. Design, Setting, and Patients Retrospective cohort study of a random 20% sample of fee-for-service Medicare beneficiaries, aged 66 years and older, who died in 2000 (n=270 202), 2005 (n=291 819), or 2009 (n=286 282). A multivariable regression model examined outcomes in 2000 and 2009 after adjustment for sociodemographic characteristics. Based on billing data, patients were classified as having a medical diagnosis of cancer, chronic obstructive pulmonary disease, or dementia in the last 180 days of life. Main Outcome Measures Site of death, place of care, rates of health care transitions, and potentially burdensome transitions (eg, health care transitions in the last 3 days of life). Results Comparing 2000, 2005, and 2009 shows a decrease in deaths in acute care hospitals and increases in intensive care unit (ICU) use in the last 30 days, hospice use at the time of death, and health care transitions at the end of the life (test of trend P < .001 for each). [GRAPHICS] In 2009, 28.4% (95% CI, 27.9%-28.5%) of hospice use at the time of death was for 3 days or less. Of these late hospice referrals, 40.3% (95% CI, 39.7%-40.8%) were preceded by hospitalization with an ICU stay. Conclusion and Relevance Among Medicare beneficiaries who died in 2009 and 2005 compared with 2000, a lower proportion died in an acute care hospital, although both ICU use and the rate of health care transitions increased in the last month of life. JAMA. 2013; 309(5): 470-477 www.jama.
- "To avoid this situation and enhance end-of-life care in long-term care facilities such as nursing homes, the National Government of Japan has implemented several policies . Nonetheless, death in hospitals is more frequent among residents of long-term care facilities in Japan (26% in 2013)  than residents in Western countries (approximately 20%)   . "
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- "The proportion of older Americans utilizing intensive care in the last month of life has steadily increased over the past two decades [1,2]. Moreover, the proportion of the US population over 65 years old is expected to double between 2000 and 2030 , with increasing demand for intensive care [2,4,5]. "
ABSTRACT: Introduction The proportion of elderly Americans admitted to the intensive care unit (ICU) in the last month of life is rising. Hence, challenging decisions regarding the appropriate use of life support are increasingly common. The objective of this study was to estimate the association between patient age and the rate of new limitations in the use of life support, independent of daily organ dysfunction status, following acute lung injury (ALI) onset. Methods This was a prospective cohort study of 490 consecutive patients without any limitations in life support at the onset of ALI. Patients were recruited from 11 ICUs at three teaching hospitals in Baltimore, Maryland, USA, and monitored for the incidence of six pre-defined limitations in life support, with adjustment for baseline comorbidity and functional status, duration of hospitalization before ALI onset, ICU severity of illness, and daily ICU organ dysfunction score. Results The median patient age was 52 (range: 18 to 96), with 192 (39%) having a new limitation in life support in the ICU. Of patients with a new limitation, 113 (59%) had life support withdrawn and died, 53 (28%) died without resuscitation, and 26 (14%) survived to ICU discharge. Each ten-year increase in patient age was independently associated with a 24% increase in the rate of limitations in life support (Relative Hazard 1.24; 95% CI 1.11 to 1.40) after adjusting for daily ICU organ dysfunction score and all other covariates. Conclusions Older critically ill patients are more likely to have new limitations in life support independent of their baseline status, ICU-related severity of illness, and daily organ dysfunction status. Future studies are required to determine whether this association is a result of differences in patient preferences by age, or differences in the treatment options discussed with the families of older versus younger patients.
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- "Furthermore, the experience of older members from Black, Asian and minority ethnic (BAME) groups is increasingly recognised as a crucial ‘tracer’ for measuring the success in achieving health and patient-preferred outcomes for the population in general , and specifically at the end of life . We therefore chose to focus on one common important outcome, place of death; which is judged by patients, their families, health professionals, policy makers and researchers to be a central issue    . In this paper, we investigate whether place of death for those who died in London from all cancer causes differed according to geographical origin (i.e. "
ABSTRACT: Ageing is a growing issue for people from UK black, Asian and minority ethnic (BAME) groups. The health experiences of these groups are recognised as a 'tracer' to measure success in end of life patient-preferred outcomes that includes place of death (PoD). To examine patterns in PoD among BAME groups who died of cancer. Mortality data for 93,375 cancer deaths of those aged ≥65 years in London from 2001-2010 were obtained from the UK Office for National Statistics (ONS). Decedent's country of birth was used as a proxy for ethnicity. Linear regression examined trends in place of death across the eight ethnic groups and Poisson regression examined the association between country of birth and place of death. 76% decedents were born in the UK, followed by Ireland (5.9%), Europe(5.4%) and Caribbean(4.3%). Most deaths(52.5%) occurred in hospital, followed by home(18.7%). During the study period, deaths in hospital declined with an increase in home deaths; trend for time analysis for those born in UK(0.50%/yr[0.36-0.64%]p<0.001), Europe (1.00%/yr[0.64-1.30%]p<0.001), Asia(1.09%/yr[0.94-1.20%]p<0.001) and Caribbean(1.03%/yr[0.72-1.30%]p<0.001). However, time consistent gaps across the geographical groups remained. Following adjustment hospital deaths were more likely for those born in Asia(Proportion ratio(PR)1.12[95%CI1.08-1.15]p<0.001) and Africa(PR 1.11[95%CI1.07-1.16]p<0.001). Hospice deaths were less likely for those born in Asia(PR 0.73 [0.68-0.80] p<0.001), Africa (PR 0.83[95%CI0.74-0.93]p<0.001), and 'other' geographical regions (PR0.90[95% 0.82-0.98]p<0.001). Home deaths were less likely for those born in the Caribbean(PR0.91[95%CI 0.85-0.98]p<0.001). Location of death varies by country of birth. BAME groups are more likely to die in a hospital and less likely to die at home or in a hospice. Further investigation is needed to determine whether these differences result from patient-centred preferences, or other environment or service-related factors. This knowledge will enable strategies to be developed to improve access to relevant palliative care and related services, where necessary.
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