Nearly one in five patients with advanced cognitive and functional impairment who are in their final days of life is subjected to a burdensome, potentially unnecessary transition in health care, such as being moved from a nursing home to a hospital, according to a reportin the Sept. 29 issue of the New England Journal of Medicine.
The frequency of such transitions varies widely from between regions of the United States, with rates as high as 37% of the cognitively impaired decedents in some states. And the rate appears to be increasing, said Pedro Gozalo, Ph.D., of the program in public health at Brown University, Providence, R.I., and his associates.
The transfer itself can be traumatic for these easily confused and physically frail patients, and it opens the door to fragmentation of care and medical errors, said the researchers. Once hospitalized, many such people near death are subjected to further disturbances such as insertion of feeding tubes or transfer to an intensive care unit. However, hospitalization is usually avoidable in patients with advanced dementia because most of the medical problems that arise at the end of life are predictable and "can be treated with equal efficacy in the nursing home," the investigators said.
They examined Medicare data covering all nursing home residents in the United States and defined "burdensome transitions" according to interviews with families and the expert opinions of geriatricians and palliative medicine specialists. Such transitions thus included transfers during the last 90 days of life from a nursing home to a hospital, transfers from a nursing home to a hospital and on to a different nursing home, and multiple hospitalizations.
The researchers retrospectively identified 474,829 nursing home residents with advanced dementia who were in their last 120 days of life in 2000-2007. Their mean age was 86 years.
A total of 90,228 of these people (19%) had at least one burdensome transition during their final 90 days of life. This included more than 55,000 who were transferred within hours of their deaths, nearly 13,000 who were transferred from one nursing home to a hospital and then to another nursing home, and more than 38,000 who were hospitalized multiple times, the researchers reported (New Engl. J. Med. 2011;365:1212-21).
The rate of burdensome transitions was lowest in Alaska (2%) and highest in Louisiana (37%). Several other southern states, California, and New York also had high rates. The lowest rates after Alaska’s were in upper-Midwest and northwestern states and Hawaii.
The nationwide rate of burdensome transitions rose from 17.4% of decedents in 2000 to 19.6% in 2007.
These transitions were more common among black and Hispanic patients than among whites, among men than women, and among patients who had no advance directive than those who did.
Burdensome transitions were associated with what the researchers identified as several markers of poor end-of-life care, including transfer to an ICU during a patient’s final days, referral to hospice care within 3 days of death, the presence of stage 4 decubitus ulcers, and insertion of a feeding tube.
Dr. Gozalo and his colleagues noted that a previous study found that "96% of family members report that comfort is the primary goal of care for their relatives with advanced dementia. Yet as we found, the pattern of transitions among nursing home residents with advanced cognitive impairment is often inconsistent with that goal."
The authors said that financial incentives probably underlie many of the burdensome transitions. "Hospitalization generally qualifies a nursing home resident with Medicaid coverage to receive Medicare payments for skilled services, which reimburse the nursing home at a higher rate. In addition, states’ Medicaid payment rates and bed-holding policies that pay nursing homes to keep a bed open for hospitalized residents are associated with increased rates of hospitalization.
"These financial incentives probably result in health care transitions that contribute not only to excessive costs but also to a poorer quality of end-of-life care," the investigators said.
"Ultimately, a decline in burdensome transitions will come about through a combination of improved provider incentives and decision making that elicits and respects the choices of patients," they said.
This study was supported by the National Institute on Aging. One of Dr. Gozalo’s associates reported being a consultant for the Manor Care nursing home chain and for Point Right, a company that provides information services in long-term care. Another associate reported ties to the Robert Wood Johnson Foundation.