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 End-Of-Life Care Increasingly More Common In Hospitals, Study Finds

About one in five dying residents of nursing homes spent their last days in hospitals between 2003 and 2007, a team of researchers at the University of Rochester reported. But up to one-third of dying residents spent time in hospitals in the last 30 days of their life, the researchers found.

When “controlling for individual-level risk factors and for facility fixed effects, the odds of nursing home residents dying in hospitals has increased significantly each year from 2003 through 2007, for short-stay and long-stay residents,” lead researcher Helen Temkin-Greener wrote for her colleagues in the latest issue of the Journal of the American Medical Directors Association.

The hospitalizations cost Medicare more than $1.6 billion every year, but they also rack up a huge emotional cost on residents, Temkin-Greener wrote.

“By and large,” she said, “the literature suggests that nursing home residents typically hope to avoid being hospitalized, particularly at the EOL [end of life] when such transfers are distressing to both the residents and their families, and result in poor outcomes, such as disorientation or delirium and hastened functional and cognitive decline.

“Regardless of such negative consequences of nursing home-to-hospital transfers, our findings demonstrate that, in the United States, each year, 35 percent of decedent nursing home residents are hospitalized in the last 30 days of life.” Temkin-Greener added.

The numbers have varied, from state to state, and year to year, but they are certainly increasing, the researchers found. In 2003, more than 159,000 nursing home residents were hospitalized at some point during their final days. The numbers rose as high as nearly 181,000 residents in 2005 but fell back to 163,000 in 2007, the researchers found.

In fact, the youngest residents were the most likely to die in the hospital. Nearly 28 percent of those who died in hospitals were younger than 65; another 26 percent were between 65 and 74, the researchers found.

The researchers canvassed a number of possibilities to explain the persistence of end-of-life hospitalizations, but lean heavily on a regulatory and funding environment where there may be perverse incentives to outsource end-of-life care to hospitals.

“Although individual risk factors are important in influencing the probability of in-hospital deaths, the health care system also presents sometimes quite formidable obstacles for nursing home residents who may wish to avoid being hospitalized at the EOL,” Temkin-Greener wrote. “State nursing home regulations, for example in New York State… require residents to be transferred to a hospital when such transfer is ‘medically appropriate,’ but the law neither defines medical appropriateness nor provides guidelines for its interpretation.”

New York has one of the highest hospitalization rates for the dying, the researchers found.

“Furthermore,” Temkin-Greener wrote, “both Medicare and Medicaid financial reimbursement policies provide additional incentives to nursing homes to hospitalize their residents. Nursing homes often lack adequate clinical infrastructure to care for the acutely ill residents. Thus, hospitalizing residents and shifting costs to a hospital setting (Medicare) is beneficial to nursing homes, even if it is not to their residents. Medicaid nursing home payment rates, case-mix-adjusted reimbursement ,and ‘bed hold’ policies also have been shown to incentivize facilities to hospitalize their Medicaid residents, including at the EOL.”

The findings should be a call to action, Temkin-Greener wrote.

“By 2030, nearly half of all Americans age 85 and older will live and die in nursing homes,” she wrote. “It is none too soon to consider a paradigm shift in nursing home policy, regulation, and investment in EOL care.”
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