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Estrada LV, Barcelona V, Dhingra L, Luchsinger JA, Dick AW, Glance LG, Stone PW. Potentially Avoidable Hospitalizations Among Historically Marginalized Nursing Home Residents. JAMA Netw Open 2024; 7:e249312. [PMID: 38696169 PMCID: PMC11066698 DOI: 10.1001/jamanetworkopen.2024.9312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 03/04/2024] [Indexed: 05/04/2024] Open
Abstract
Importance Nursing home (NH) transfers to hospitals are common and have been associated with cognitive decline; approximately 45% of NH hospital transfers are potentially avoidable hospitalizations (PAHs). Objective To determine PAH incidence for historically marginalized NH residents with severe cognitive impairment compared with non-Hispanic White residents. Design, Setting, and Participants This cross-sectional study merged 2018 Centers for Medicaid & Medicare Services datasets and LTCFocus, a public dataset on US NH care, for US NH residents aged 65 years and older who had a hospitalization. Analyses were performed from January to May 2022. Exposure Race and ethnicity of NH residents. Main Outcomes and Measures Racial and ethnic differences in resident-level annual rates of PAHs were estimated for residents with and without severe cognitive impairment (measured using the Cognitive Function Scale), controlling for resident characteristics, comorbidities, dual eligibility, and time at risk. PAHs were defined as NH hospital transfers that resulted from neglectful NH care or for which NH treatment would have been appropriate. Results Of 2 098 385 NH residents nationwide included in the study, 7151 (0.3%) were American Indian or Alaska Native, 39 873 (1.9%) were Asian, 229 112 (10.9%) were Black or African American, 99 304 (4.7%) were Hispanic, 2785 (0.1%) were Native Hawaiian or Pacific Islander, 1 713 670 (81.7%) were White, and 6490 (0.3%) were multiracial; 1 355 143 (64.6%) were female; 128 997 (6.2%) were severely cognitively impaired; and the mean (SD) age was 81.8 (8.7) years. PAH incidence rate ratios (IRRs) were significantly greater for residents with severe cognitive impairment compared with those without. In unadjusted analyses comparing historically marginalized residents with severe cognitive impairment vs non-Hispanic White residents with severe cognitive impairment, American Indian or Alaska Native residents had a 49% higher PAH incidence (IRR, 1.49 [95% CI, 1.10-2.01]), Black or African American residents had a 64% higher incidence (IRR, 1.64 [95% CI, 1.48-1.81]), and Hispanic residents had a 45% higher incidence (IRR, 1.45 [95% CI, 1.29-1.62]). Higher incidences persisted for historically marginalized residents with severe cognitive impairment vs non-Hispanic White residents with severe cognitive impairment in adjusted analyses. Asian residents had a 24% higher PAH incidence (IRR, 1.24 [95% CI, 1.06-1.45]), Black or African American residents had a 48% higher incidence (IRR, 1.48 [95% CI, 1.36-1.60]), and Hispanic residents had a 27% higher incidence (IRR, 1.27 [95% CI, 1.16-1.39]). Conclusions and Relevance In this cross-sectional study of PAHs, compared with non-Hispanic White NH residents, historically marginalized residents had increased PAH incidence. In the presence of severe cognitive impairment, incidence rates increased significantly compared with rates for residents without severe cognitive impairment. These results suggest that identification of residents with severe cognitive impairment and proper NH care may help prevent further cognitive decline by avoiding PAHs.
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Affiliation(s)
- Leah V. Estrada
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Lara Dhingra
- MJHS Institute for Innovation in Palliative Care, New York, New York
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - José A. Luchsinger
- Departments of Medicine and Epidemiology, Columbia University Irving Medical Center
| | | | - Laurent G. Glance
- RAND Corporation, Boston, Massachusetts
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York
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Scott MM, Ménard A, Sun AH, Murmann M, Ramzy A, Rasaputra P, Fleming M, Orosz Z, Huynh C, Welch V, Cooper-Reed A, Hsu AT. Building evidence to advance health equity: a systematic review on care-related outcomes for older, minoritised populations in long-term care homes. Age Ageing 2024; 53:afae059. [PMID: 38557665 PMCID: PMC10982852 DOI: 10.1093/ageing/afae059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Advancing health equity requires more contextualised evidence. OBJECTIVES To synthesise published evidence using an existing framework on the origins of health disparities and determine care-related outcome disparities for residents of long-term care, comparing minoritised populations to the context-specific dominant population. DESIGN Systematic review. SUBJECTS Residents of 24-hour long-term care homes. METHODS The protocol was registered a priori with PROSPERO (CRD42021269489). Literature published between 1 January 2000 and 26 September 2021, was searched, including studies comparing baseline characteristics and outcomes in minoritised versus dominant populations. Dual screening, two-reviewer verification for extraction, and risk of bias assessments were conducted to ensure rigour. Studies were synthesized using a conceptual framework to contextualise evidence according to multi-level factors contributing to the development of care disparities. RESULTS Twenty-one of 34 included studies demonstrated disparities in care outcomes for minoritised groups compared to majority groups. Thirty-one studies observed differences in individual-level characteristics (e.g. age, education, underlying conditions) upon entry to homes, with several outcome disparities (e.g. restraint use, number of medications) present at baseline and remaining or worsening over time. Significant gaps in evidence were identified, particularly an absence of literature on provider information and evidence on the experience of intersecting minority identities that contribute to care-related outcome disparities in long-term care. CONCLUSION This review found differences in minoritised populations' care-related outcomes. The findings provide guidance for future health equity policy and research-supporting diverse and intersectional capacity building in long-term care.
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Affiliation(s)
- Mary M Scott
- The Public Health Agency of Canada, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alixe Ménard
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Annie H Sun
- Bruyere Research Institute, Ottawa, ON, Canada
| | - Maya Murmann
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
| | - Amy Ramzy
- Bruyere Research Institute, Ottawa, ON, Canada
| | | | - Michelle Fleming
- Bruyere Research Institute, Ottawa, ON, Canada
- Ontario Centres for Learning, Research and Innovation in Long-Term Care, Ottawa, ON, Canada
| | - Zsófia Orosz
- Bruyere Research Institute, Ottawa, ON, Canada
- Ontario Centres for Learning, Research and Innovation in Long-Term Care, Ottawa, ON, Canada
| | - Chau Huynh
- Bruyere Research Institute, Ottawa, ON, Canada
| | - Vivian Welch
- Bruyere Research Institute, Ottawa, ON, Canada
- The Campbell Collaboration, Philadelphia, PA, USA
| | | | - Amy T Hsu
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
- Ontario Centres for Learning, Research and Innovation in Long-Term Care, Ottawa, ON, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
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Bowblis JR, Akosionu O, Ng W, Shippee TP. Identifying Nursing Homes With Diverse Racial and Ethnic Resident Compositions: The Importance of Group Heterogeneity and Geographic Context. Med Care Res Rev 2023; 80:175-186. [PMID: 36408838 DOI: 10.1177/10775587221134870] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Racial/ethnic composition of nursing home (NH) plays a particularly important role in NH quality. A key methodological issue is defining when an NH serves a low versus high proportion of racially/ethnically diverse residents. Using the Minimum Data Set from 2015 merged with Certification and Survey Provider Enhanced Reports, we calculated the racial/ethnic composition of U.S.-based NHs for Black or Hispanic residents specifically, and a general Black, Indigenous, and People of Color (BIPOC) grouping for long-stay residents. We examined different definitions of having a high racial/ethnic composition by varying percentile thresholds of composition, state-specific and national thresholds, and restricting composition to BIPOC residents as well as only Black and Hispanic residents. NHs with a high racial/ethnic composition have different facility characteristics than the average NH. Based on this, we make suggestions for how to identify NHs with diverse racial/ethnic resident compositions.
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Affiliation(s)
| | | | - Weiwen Ng
- University of Minnesota, Twin Cities, Minneapolis, USA
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Estrada LV, Harrison JM, Dick AW, Luchsinger JA, Dhingra L, Stone PW. Examining Regional Differences in Nursing Home Palliative Care for Black and Hispanic Residents. J Palliat Med 2022; 25:1228-1235. [PMID: 35143358 PMCID: PMC9347389 DOI: 10.1089/jpm.2021.0416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Approximately one-quarter of all deaths in the United States occur in nursing homes (NHs). Palliative care has the potential to improve NH end-of-life care, but more information is needed on the provision of palliative care in NHs serving Black and Hispanic residents. Objective: To determine whether palliative care services in United States NHs are associated with differences in the concentrations of Black and Hispanic residents, respectively, and the impact by region. Design: We conducted a cross-sectional analysis. The outcome was NH palliative care services (measured by an earlier national survey); total scores ranged from 0 to 100 (higher scores indicated more services). Other data included the Minimum Data Set and administrative data. The independent variables were concentration of Black and Hispanic residents (i.e., <3%, 3-10%, >10%), respectively, and models were stratified by region (i.e., Northeast, Midwest, South and West). We compared unadjusted, weighted mean palliative care services by the concentration of Black and Hispanic residents and computed NH-level multivariable linear regressions. Setting/Subjects: Eight hundred sixty-nine (weighted n = 15,020) NHs across the United States. Results: Multivariable analyses showed fewer palliative care services provided in NHs with greater concentrations of Black and Hispanic residents. Fewer palliative care services were reported in NHs in the Northeast, for which >10% of the resident population was Black, and NHs in the West for which >10% was Hispanic versus NHs with <3% of the population being Black and Hispanic (-13.7; p < 0.001 and -9.3; p < 0.05, respectively). Conclusion: We observed differences in NH palliative care by region and with greater concentration of Black and Hispanic residents. Our findings suggest that greater investment in NH palliative care services may be an important strategy to advance health equity in end-of-life care for Black and Hispanic residents.
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Affiliation(s)
- Leah V Estrada
- Center for Health Policy, Columbia University School of Nursing, New York, New York, USA
| | | | | | - José A Luchsinger
- Departments of Medicine and Epidemiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Lara Dhingra
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA.,Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Patricia W Stone
- Center for Health Policy, Columbia University School of Nursing, New York, New York, USA
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Estrada LV, Agarwal M, Stone PW. Racial/Ethnic Disparities in Nursing Home End-of-Life Care: A Systematic Review. J Am Med Dir Assoc 2021; 22:279-290.e1. [PMID: 33428892 DOI: 10.1016/j.jamda.2020.12.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Health disparities are pervasive in nursing homes (NHs), but disparities in NH end-of-life (EOL) care (ie, hospital transfers, place of death, hospice use, palliative care, advance care planning) have not been comprehensively synthesized. We aim to identify differences in NH EOL care for racial/ethnic minority residents. DESIGN A systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and registered in PROSPERO (CRD42020181792). SETTING AND PARTICIPANTS Older NH residents who were terminally ill or approaching the EOL, including racial/ethnic minority NH residents. METHODS Three electronic databases were searched from 2010 to May 2020. Quality was assessed using the Newcastle-Ottawa Scale. RESULTS Eighteen articles were included, most (n = 16) were good quality and most (n = 15) used data through 2010. Studies varied in definitions and grouping of racial/ethnic minority residents. Four outcomes were identified: advance care planning (n = 10), hospice (n = 8), EOL hospitalizations (n = 6), and pain management (n = 1). Differences in EOL care were most apparent among NHs with higher proportions of Black residents. Racial/ethnic minority residents were less likely to complete advance directives. Although hospice use was mixed, Black residents were consistently less likely to use hospice before death. Hispanic and Black residents were more likely to experience an EOL hospitalization compared with non-Hispanic White residents. Racial/ethnic minority residents experienced worse pain and symptom management at the EOL; however, no articles studied specifics of palliative care (eg, spiritual care). CONCLUSIONS AND IMPLICATIONS This review identified NH health disparities in advance care planning, EOL hospitalizations, and pain management for racial/ethnic minority residents. Research is needed that uses recent data, reflective of current NH demographic trends. To help reduce EOL disparities, language services and cultural competency training for staff should be available in NHs with higher proportions of racial/ethnic minorities.
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Affiliation(s)
- Leah V Estrada
- Columbia University School of Nursing, New York, NY, USA.
| | - Mansi Agarwal
- Columbia University School of Nursing, New York, NY, USA
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Qureshi D, Schumacher C, Talarico R, Lapenskie J, Tanuseputro P, Scott M, Hsu A. Describing Differences Among Recent Immigrants and Long-Standing Residents Waiting for Long-Term Care: A Population-Based Retrospective Cohort Study. J Am Med Dir Assoc 2021; 22:648-55. [PMID: 32972870 DOI: 10.1016/j.jamda.2020.07.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Immigrants often face many unique cultural and logistical challenges in their health care that differ from nonimmigrants. We sought to describe and compare characteristics and the time to placement between recent immigrants and long-standing residents waiting for long-term care (LTC). DESIGN Population-based retrospective cohort study using linked health administrative data. SETTING/PARTICIPANTS We examined all Ontario residents aged 65 years or older who were placed on the LTC waitlist between January 2007 and December 2010. We defined recent immigrants as those granted permanent residency or citizenship status in Canada after 1985; all others were defined as long-standing residents. METHODS The primary outcome was the number of days on the waitlist before LTC entry, indexed on the incident waitlist record, with a maximum follow-up until December 2012. A generalized estimating equation model was used to identify factors associated with the number of days spent waiting for LTC entry. RESULTS We identified 56,031 individuals on the LTC waitlist, among whom 3.0% were recent immigrants. Compared with long-standing residents, recent immigrants were younger (age ≥80: 66.6% vs. 72.7%), from lower income neighborhoods (bottom 2 brackets: 50.0% vs. 44.0%), and had fewer comorbidities (≥5: 41.6% vs. 36.5%). A larger proportion of caregivers of recent immigrants reported being unable to continue providing care (21.6% vs. 16.7%) and expressed greater feelings of distress (26.9% vs. 20.7%). The median wait time to LTC placement was 165 days for immigrants versus 126 days for long-standing residents. Applying to a cultural/ethnic-specific home [Arithmetic Mean Ratio (AMR) = 1.32, 95% Confidence Interval (CI) 1.11-1.56] and being an immigrant (AMR = 1.22, 95% CI 1.15-1.30) was associated with significantly longer wait times to placement, adjusting for covariates. CONCLUSIONS/IMPLICATIONS Recent immigrants vary considerably from long-standing residents, and tend to wait longer to be placed into LTC homes. Future research is necessary to understand how we can reduce wait times to LTC entry for the aging population, with a particular focus on immigrants who are often highly disadvantaged.
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Jeong A, Lapenskie J, Talarico R, Hsu AT, Tanuseputro P. Health Outcomes of Immigrants in Nursing Homes: A Population-Based Retrospective Cohort Study in Ontario, Canada. J Am Med Dir Assoc 2020; 21:740-746.e5. [PMID: 32536433 DOI: 10.1016/j.jamda.2020.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/03/2020] [Accepted: 03/02/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Older adults account for a significant portion of Canadian immigrants, yet characteristics and health outcomes of older immigrants in nursing homes have not been studied. We aimed to describe the prevalence of immigrants living in nursing homes, their characteristics, and their hospitalization and mortality rates compared to long-term residents in the first year of entry to nursing homes. DESIGN Population-based, retrospective cohort study using linked health administrative databases. SETTING AND PARTICIPANTS We assessed all incident admissions into publicly funded nursing homes in Ontario between April 2013 and March 2016. Immigrants were defined as those who arrived in Canada after 1985; long-term residents are those who arrived before 1985 or are Canadian-born. METHODS The primary outcome was all-cause hospitalization and mortality rates within 1 year of nursing home entry. Nested Cox proportional hazards models were estimated to explore the associations of facility, demographic, and clinical characteristics to the primary outcomes. RESULTS Immigrants comprised 4.4% of residents in Ontario's nursing homes, compared to 13.9% in the general population. The majority were from East and Southeast Asia (52.2%), and more than half (53.9%) had no competency in either official language on arrival in Canada. At the time of nursing home entry, immigrants were younger than long-term residents but had greater functional and cognitive impairments. Immigrants had a lower rate of mortality [hazard ratio 0.58, 95% confidence interval (CI) 0.51, 0.68; P < .001] but were more likely to be hospitalized (hazard ratio 1.14, 95% CI 1.06, 1.23; P < .001). Adjusting for language ability, the effect of immigrant status on hospitalization was not statistically significant. CONCLUSIONS AND IMPLICATIONS Despite greater functional and cognitive impairments, immigrants in nursing homes had lower mortality than long-term residents, potentially reflecting the "healthy immigrant effect." Inability to speak English was associated with increased risk of hospitalization, highlighting the need for strategies to overcome communication barriers.
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Shippee TP, Ng W, Bowblis JR. Does Living in a Higher Proportion Minority Facility Improve Quality of Life for Racial/Ethnic Minority Residents in Nursing Homes? Innov Aging 2020; 4:igaa014. [PMID: 32529052 PMCID: PMC7272785 DOI: 10.1093/geroni/igaa014] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Indexed: 11/12/2022] Open
Abstract
Background and Objectives The proportion of racial/ethnic minority older adults in nursing homes (NHs) has increased dramatically and will surpass the proportion of white adults by 2030.Yet, little is known about minority groups’ experiences related to the quality of life (QOL). QOL is a person-centered measure, capturing multiple aspects of well-being. NH quality has been commonly measured using clinical care indicators, but there is growing recognition for the need to include QOL. This study examines the role of individual race/ethnicity, facility racial/ethnic composition, and the interaction of both for NH resident QOL. Research Design and Methods We used a unique state-level data set that includes self-reported QOL surveys with a random sample of long-stay Minnesota NH residents, using a multidimensional measure of QOL. These surveys were linked to resident clinical data from the Minimum Dataset 3.0 and facility-level characteristics. Minnesota is one of the two states in the nation that collects validated QOL measures, linked to data on resident and detailed facility characteristics. We used mixed-effects models, with random intercepts to model summary QOL score and individual domains. Results We identified significant racial disparities in NH resident QOL. Minority residents report significantly lower QOL scores than white residents, and NHs with higher proportion minority residents have significantly lower QOL scores. Minority residents have significantly lower adjusted QOL than white residents, whether they are in low- or high-minority facilities, indicating a remaining gap in individual care needs. Discussion and Implications The findings highlight system-level racial disparities in NH residents QOL, with residents who live in high-proportion minority NHs facing the greatest threats to their QOL. Efforts need to focus on reducing racial/ethnic disparities in QOL, including potential public reporting (similar to quality of care) and resources and attention to provision of culturally sensitive care in NHs to address residents’ unique needs.
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Affiliation(s)
- Tetyana P Shippee
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - Weiwen Ng
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - John R Bowblis
- Department of Economics, Farmer School of Business, Miami University, Oxford, Ohio
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Abstract
BACKGROUND End-of-life hospitalizations in nursing home residents are common, although they are often burdensome and potentially avoidable. AIM We aimed to summarize the existing evidence on end-of-life hospitalizations in nursing home residents. DESIGN Systematic review (PROSPERO registration number CRD42017072276). DATA SOURCES A systematic literature search was carried out in PubMed, CINAHL, and Scopus (date of search 9 April 2019). Studies were included if they reported proportions of in-hospital deaths or hospitalizations of nursing home residents in the last month of life. Two authors independently selected studies, extracted data, and assessed the quality of studies. Median with interquartile range was used to summarize proportions. RESULTS A total of 35 studies were identified, more than half of which were from the United States (n = 18). While 29 studies reported in-hospital deaths, 12 studies examined hospitalizations during the last month of life. The proportion of in-hospital deaths varied markedly between 5.9% and 77.1%, with an overall median of 22.6% (interquartile range: 16.3%-29.5%). The proportion of residents being hospitalized during the last month of life ranged from 25.5% to 69.7%, and the median was 33.2% (interquartile range: 30.8%-38.4%). Most studies investigating the influence of age found that younger age was associated with a higher likelihood of end-of-life hospitalization. Four studies assessed trends over time, showing heterogeneous findings. CONCLUSION There is a wide variation in end-of-life hospitalizations, even between studies from the same country. Overall, such hospitalizations are common among nursing home residents, which indicates that interventions tailored to each specific health care system are needed to improve end-of-life care.
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Affiliation(s)
- Katharina Allers
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Rieke Schnakenberg
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
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Cai S, Miller SC, Gozalo PL. Nursing Home-Hospice Collaboration and End-of-Life Hospitalizations Among Dying Nursing Home Residents. J Am Med Dir Assoc 2017; 19:439-443. [PMID: 29191764 DOI: 10.1016/j.jamda.2017.10.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 10/18/2017] [Accepted: 10/19/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Nursing homes (NHs) collaboration with hospices appears to improve end-of-life (EOL) care among dying NH residents. However, the potential benefits of NH-hospice collaboration may vary with the patterns of this collaboration. This study examines the relationship between the attributes of NH-hospice collaboration, especially the exclusivity of NH-hospice collaboration (ie, the number of hospice providers in a NH), and EOL hospitalizations among dying NH residents. DESIGN This national retrospective cohort study linked 2000-2009 NH assessments (ie, the Minimum Data Set 2.0) and Medicare data. A linear probability model with facility fixed-effects was estimated to examine the relationship between EOL hospitalization and the attributes of NH-hospice collaborations, adjusting for individual and facility characteristics. We also performed a set of sensitivity analyses, including stratified analyses by volume of hospice services in a NH and stratified analyses by rural vs urban NH locations. SETTINGS All Medicare and/or Medicaid certified US NHs with at least 8 years of data and at least 30 beds. PARTICIPANTS NH decedents resided in Medicare and/or Medicaid certified NHs in the US between 2000 and 2009. We restricted the analyses to those continuously enrolled in Medicare fee-for-service in the last 6 months of life and those who were in NHs for the last 30 days of life. In total, we identified 2,954,276 NH decedents over the study period. MEASUREMENTS The outcome variable was measured as dichotomous, indicating whether a dying NH resident was hospitalized in the last 30 days of life. The attributes of NH-hospice collaboration were measured by the volume of hospice services (defined as the ratio of number of hospice days to the total NH days per NH per calendar year) and the number of hospice providers in a NH (defined as the number of unique hospice providers in a NH per year). We categorized NHs into groups based on the number of hospice providers (1, 2 or 3, and ≥4) in the NH, and conducted sensitivity analysis using a different categorization (1, 2, and 3+ hospice providers). RESULTS The pattern of NH-hospice collaboration changed significantly over years; the average number of hospices in a NH increased from 1.4 in 2000 to 3.2 in 2009. The volume of NH-hospice collaboration also increased substantially. The multivariate regression analyses indicated that having more hospice providers in the NH was not associated with lower risks of EOL hospitalizations. After accounting for individual and facility characteristics, increasing hospice providers from 1 to at least 4 was associated with an overall 1 percentage point increase in the likelihood of EOL hospitalizations among dying residents (P < .01), and such relationship remained in NHs with moderate or high volume NHs in the stratified analyses. Stratified analysis by rural vs urban NHs suggested that the relationship between the number of hospice providers and EOL hospitalizations was mainly in urban NHs. CONCLUSIONS More hospice providers in the NH was not associated with lower EOL hospitalizations, especially among NHs with relatively high volume of hospice services.
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Affiliation(s)
- Shubing Cai
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, NY.
| | - Susan C Miller
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI; Providence Veterans Affairs Medical Center, Providence, RI
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Abstract
Prior research has shown a relationship between falls, hospitalizations, and depression among older adults in nursing home settings, but few studies have explored these relationships for younger and older adults in residential care facilities. This study examined risk factors for hospitalizations among assisted living residents. Using the 2010 National Survey of Residential Care Facilities, the study found that 24% of residents had a hospital stay in the past year. Residents with falls were more than twice as likely to have a hospitalization. For younger residents, depression was a key risk factor (OR = 1.74, p < .01). However, older residents with dementia had a lower risk of hospitalization (OR = 0.71, p < .01). More attention is needed to prevent falls and identify residents with depression and severe mental illness, who are at greater risk of hospitalization. Reducing avoidable hospitalizations can improve well-being for older and younger adults in residential care facilities.
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Song MK, Ward SE, Lin FC, Hamilton JB, Hanson LC, Hladik GA, Fine JP. Racial Differences in Outcomes of an Advance Care Planning Intervention for Dialysis Patients and Their Surrogates. J Palliat Med 2016; 19:134-42. [PMID: 26840848 DOI: 10.1089/jpm.2015.0232] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND African Americans' beliefs about end-of-life care may differ from those of whites, but racial differences in advance care planning (ACP) outcomes are unknown. OBJECTIVE The aim of this study was to compare the efficacy of an ACP intervention on preparation for end-of-life decision making and post-bereavement outcomes for African Americans and whites on dialysis. METHOD A secondary analysis of data from a randomized trial comparing an ACP intervention (Sharing Patient's Illness Representations to Increase Trust [SPIRIT]) with usual care was conducted. There were 420 participants, 210 patient-surrogate dyads (67.4% African Americans), recruited from 20 dialysis centers in North Carolina. The outcomes of preparation for end-of-life decision making included dyad congruence on goals of care, surrogate decision-making confidence, a composite of the two, and patient decisional conflict assessed at 2, 6, and 12 months post-intervention. Surrogate bereavement outcomes included anxiety, depression, and post-traumatic distress symptoms assessed at 2 weeks, and at 3 and 6 months after the patient's death. RESULTS SPIRIT was superior to usual care in improving dyad congruence (odds ration [OR] = 2.31, p = 0.018), surrogate decision-making confidence (β = 0.18, p = 0.021), and the composite (OR = 2.19, p = 0.028) 2 months post-intervention, but only for African Americans. SPIRIT reduced patient decisional conflict at 6 months for whites and at 12 months for African Americans. Finally, SPIRIT was superior to usual care in reducing surrogates' bereavement depressive symptoms for African Americans but not for whites (β = -3.49, p = 0.003). CONCLUSION SPIRIT was effective in improving preparation for end-of-life decision-making and post-bereavement outcomes in African Americans.
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Affiliation(s)
- Mi-Kyung Song
- 1 Nell Hodgson School of Nursing, Emory University , Atlanta, Georgia
| | - Sandra E Ward
- 2 School of Nursing, University of Wisconsin-Madison , Madison, Wisconsin
| | - Feng-Chang Lin
- 3 School of Public Health, Department of Biostatistics, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| | - Jill B Hamilton
- 4 School of Nursing, Johns Hopkins University , Baltimore, Maryland
| | - Laura C Hanson
- 5 School of Medicine, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| | | | - Jason P Fine
- 3 School of Public Health, Department of Biostatistics, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
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13
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Birchley G, Jones K, Huxtable R, Dixon J, Kitzinger J, Clare L. Dying well with reduced agency: a scoping review and thematic synthesis of the decision-making process in dementia, traumatic brain injury and frailty. BMC Med Ethics 2016; 17:46. [PMID: 27461340 PMCID: PMC4962460 DOI: 10.1186/s12910-016-0129-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/13/2016] [Indexed: 12/02/2022] Open
Abstract
Background In most Anglophone nations, policy and law increasingly foster an autonomy-based model, raising issues for large numbers of people who fail to fit the paradigm, and indicating problems in translating practical and theoretical understandings of ‘good death’ to policy. Three exemplar populations are frail older people, people with dementia and people with severe traumatic brain injury. We hypothesise that these groups face some over-lapping challenges in securing good end-of-life care linked to their limited agency. To better understand these challenges, we conducted a scoping review and thematic synthesis. Methods To capture a range of literature, we followed established scoping review methods. We then used thematic synthesis to describe the broad themes emerging from this literature. Results Initial searches generated 22,375 references, and screening yielded 49, highly heterogeneous, studies that met inclusion criteria, encompassing 12 countries and a variety of settings. The thematic synthesis identified three themes: the first concerned the processes of end-of-life decision-making, highlighting the ambiguity of the dominant shared decision-making process, wherein decisions are determined by families or doctors, sometimes explicitly marginalising the antecedent decisions of patients. Despite this marginalisation, however, the patient does play a role both as a social presence and as an active agent, by whose actions the decisions of those with authority are influenced. The second theme examined the tension between predominant notions of a good death as ‘natural’ and the drive to medicalise death through the lens of the experiences and actions of those faced with the actuality of death. The final theme considered the concept of antecedent end-of-life decision-making (in all its forms), its influence on policy and decision-making, and some caveats that arise from the studies. Conclusions Together these three themes indicate a number of directions for future research, which are likely to be applicable to other conditions that result in reduced agency. Above all, this review emphasises the need for new concepts and fresh approaches to end of life decision-making that address the needs of the growing population of frail older people, people with dementia and those with severe traumatic brain injury. Electronic supplementary material The online version of this article (doi:10.1186/s12910-016-0129-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Giles Birchley
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK.
| | - Kerry Jones
- Faculty of Health and Social Care, The Open University, Milton Keynes, UK
| | - Richard Huxtable
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | - Jeremy Dixon
- Department of Social and Policy Sciences, University of Bath, Bath, UK
| | - Jenny Kitzinger
- Coma and Disorders of Consciousness Research Centre, Cardiff University, Cardiff, UK
| | - Linda Clare
- REACH: The Centre for Research in Ageing and Cognitive Health, University of Exeter, Exeter, UK
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Abstract
BACKGROUND Living in a multicultural society is characterized by different attitudes caused by a variety of religions and cultures. In intensive care medicine such a variety of cultural aspects with respect to pain, shame, bodiliness, dying and death is of importance in this scenario. AIM To assess the importance of cultural and religious attitudes in the face of foreignness in intensive care medicine and nursing. Notification of misunderstandings and misinterpretations in communication and actions. MATERIAL AND METHODS An analysis of the scientific literature was carried out and typical intercultural conflict burden situations regarding the management of brain death, organ donation and end of life decisions are depicted. RESULTS Specific attitudes are found in various religions or cultures regarding the change of a therapeutic target, the value of the patient's living will and the organization of rituals for dying. Intercultural conflicts are mostly due to misunderstandings, assessment differences, discrimination and differences in values. CONCLUSION Intercultural competence is crucial in intensive care medicine and includes knowledge of social and cultural influences of different attitudes on health and illness, the abstraction from own attitudes and the acceptance of other or foreign attitudes.
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Affiliation(s)
- T Bein
- Klinik für Anästhesiologie, Universitätsklinikum, 93042, Regensburg, Deutschland,
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15
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Burgio KL, Williams BR, Dionne-Odom JN, Redden DT, Noh H, Goode PS, Kvale E, Bakitas M, Bailey FA. Racial Differences in Processes of Care at End of Life in VA Medical Centers: Planned Secondary Analysis of Data from the BEACON Trial. J Palliat Med 2016; 19:157-63. [PMID: 26840851 PMCID: PMC4939451 DOI: 10.1089/jpm.2015.0311] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2015] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Racial differences exist for a number of health conditions, services, and outcomes, including end-of-life (EOL) care. OBJECTIVE The aim of the study was to examine differences in processes of care in the last 7 days of life between African American and white inpatients. METHODS Secondary analysis was conducted of data collected in the Best Practices for End-of-Life Care for Our Nation's Veterans (BEACON) trial (conducted 2005-2011). Subjects were 4891 inpatient decedents in six Veterans Administration Medical Centers. Data were abstracted from decedents' medical records. Multi-variable analyses were conducted to examine the relationship between race and each of 18 EOL processes of care controlling for patient characteristics, study site, year of death, and whether the observation was pre- or post-intervention. RESULTS The sample consisted of 1690 African American patients (34.6%) and 3201 white patients (65.4%). African Americans were less likely to have: do not resuscitate (DNR) orders (odds ratio [OR]: 0.67; p = 0.004), advance directives (OR: 0.71; p = 0.023), active opioid orders (OR: 0.64, p = 0.0008), opioid medications administered (OR: 0.61, p = 0.004), benzodiazepine orders (OR: 0.68, p < 0.0001), benzodiazepines administered (OR: 0.61, p < 0.0001), antipsychotics administered (OR: 0.73, p = 0.004), and steroids administered (OR: 0.76, p = 0.020). Racial differences were not found for other processes of care, including palliative care consultation, pastoral care, antipsychotic and steroid orders, and location of death. CONCLUSIONS Racial differences exist in some but not all aspects of EOL care. Further study is needed to understand the extent to which racial differences reflect different patient needs and preferences and whether interventions are needed to reduce disparities in patient/family education or access to quality EOL care.
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Affiliation(s)
- Kathryn L. Burgio
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, Alabama, and Atlanta, Georgia
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Beverly R. Williams
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, Alabama, and Atlanta, Georgia
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - David T. Redden
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, Alabama, and Atlanta, Georgia
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Patricia S. Goode
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, Alabama, and Atlanta, Georgia
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth Kvale
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, Alabama, and Atlanta, Georgia
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Marie Bakitas
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, Alabama, and Atlanta, Georgia
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - F. Amos Bailey
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, Alabama, and Atlanta, Georgia
- Department of Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Medicine, University of Colorado, Denver, Colorado
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Drageset J, Eide GE, Ranhoff AH. Better health-related quality of life (mental component summary), having a higher level of education, and being less than 75 years of age are predictors of hospital admission among cognitively intact nursing home residents: a 5-year follow-up study. Patient Prefer Adherence 2016; 10:275-82. [PMID: 27022249 PMCID: PMC4788368 DOI: 10.2147/ppa.s92135] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To study whether health-related quality of life (HRQOL), activities of daily living (ADL), and anxiety and depression symptoms affect the risk of hospital admission and potential interactions with having a cancer diagnosis. METHODS This study was a prospective observational study with 5-year follow-up and analyzed the follow-up data on hospital admissions until 2010 using baseline data from 227 cognitively intact nursing home (NH) residents (60 of whom had cancer) in 2004-2005. Data on HRQOL were collected by using the Short Form-36 Health Survey, divided into physical component summary (PCS) and mental component summary (MCS), and symptoms of anxiety and depression were collected by using the Hospital Anxiety and Depression Scale (HADS). ADL were obtained from registered observation and sociodemographic variables, diagnoses, and hospital admissions from the NH records. Personal identification numbers were linked to the record systems of the hospitals, thereby registering all hospital admissions. We analyzed the time elapsing between inclusion and the first hospital admission. RESULTS Residents with higher HRQOL (MCS) had significantly more hospital admissions after adjustment for age, sex, marital status, education, and comorbidity. HRQOL (PCS), ADL, depression, and anxiety symptoms were not associated with hospital admissions. Cancer increased the risk after adjustment for all other risk factors but did not increase the effects of MCS, PCS, ADL, or depression or anxiety symptoms. Having a higher level of education and being less than 75 years of age were associated with hospitalization. The residents diagnosed with cancer had the most days in hospital related to diseases of the respiratory system and cancer, and diseases of the circulatory and respiratory systems were more frequent among the residents without a cancer diagnosis. CONCLUSION Better self-reported HRQOL (MCS) was associated with hospital admissions, whereas self-reported HRQOL (PCS), ADL, and depression and anxiety symptoms were not. Cancer increased the risk but not the effects of MCS, PCS, ADL, or depression or anxiety symptoms. Having a higher level of education and being less than 75 years of age were also associated with hospitalization.
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Affiliation(s)
- Jorunn Drageset
- Department of Nursing, Faculty for Health and Social Science, Bergen University College, Bergen, Norway
- Department of Public Health and Primary Care, University of Bergen, Bergen, Norway
- Correspondence: Jorunn Drageset, Department of Nursing, Faculty for Health and Social Science, Bergen University College, Inndalsveien 28, N-5063 Bergen Norway, Tel +47 55 585 589, Fax +47 55 585 556, Email
| | - Geir Egil Eide
- Centre for Clinical Research, Western Norway Health Region Authority, Bergen, Norway
- Research Group for Lifestyle Epidemiology, Department of Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Anette Hylen Ranhoff
- Kavli Research Centre for Ageing and Dementia, Haraldsplass Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
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17
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Tappen RM, Worch SM, Elkins D, Hain DJ, Moffa CM, Sullivan G. Remaining in the nursing home versus transfer to acute care: resident, family, and staff preferences. J Gerontol Nurs 2015; 40:48-57. [PMID: 25275783 DOI: 10.3928/00989134-20140807-01] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 07/03/2014] [Indexed: 11/20/2022]
Abstract
Resident and family insistence on transfer is a major factor in the occurrence of potentially avoidable transfers from nursing homes (NHs) to acute care. The purpose of this study was to explore resident, family, and staff preferences regarding transfer to acute care. A sample of 271 NH residents, family members, staff, and medical providers were interviewed. Seventy-seven percent of residents reported that they had not given any thought to the question of whether they would want to be transferred to acute care. Family members wanted more information than residents, but more residents (39%) thought they should be fully involved in the transfer decision than their family members (12%) or staff (12%). Staff preferred keeping residents in the NH. Families were divided between transferring residents and having them remain in the NH. More residents indicated that their desire to transfer would depend on the severity of their condition and their prognosis. Ethnic group differences were noted. Results suggest that discussion of this issue should occur soon after admission and that differences in perspectives may be expected from those involved.
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18
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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.
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19
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Xing J, Mukamel DB, Temkin-Greener H. Hospitalizations of nursing home residents in the last year of life: nursing home characteristics and variation in potentially avoidable hospitalizations. J Am Geriatr Soc 2013; 61:1900-8. [PMID: 24219191 DOI: 10.1111/jgs.12517] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES 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. DESIGN Retrospective. SETTING Hospitalizations originating from NHs. PARTICIPANTS Long-term care NH residents who died in 2007. MEASUREMENTS 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Jingping Xing
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
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20
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Lee J, Cheng J, Au KM, Yeung F, Leung MT, Ng J, Hui E, Lo R, Woo J. Improving the Quality of End-of-Life Care in Long-Term Care Institutions. J Palliat Med 2013; 16:1268-74. [DOI: 10.1089/jpm.2013.0190] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jenny Lee
- Department of Medicine and Geriatrics, Shatin Hospital, Hong Kong
| | - Joanna Cheng
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Kar-ming Au
- Community Outreach Service Team, Prince of Wales Hospital, Hong Kong
| | - Fannie Yeung
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Mei-tak Leung
- Community Outreach Service Team, Prince of Wales Hospital, Hong Kong
| | - Joey Ng
- Community Outreach Service Team, Prince of Wales Hospital, Hong Kong
| | - Elsie Hui
- Department of Medicine and Geriatrics, Shatin Hospital, Hong Kong
| | - Raymond Lo
- Department of Medicine and Geriatrics, Shatin Hospital, Hong Kong
| | - Jean Woo
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
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21
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Chisholm L, Weech-Maldonado R, Laberge A, Lin FC, Hyer K. Nursing home quality and financial performance: does the racial composition of residents matter? Health Serv Res 2013; 48:2060-80. [PMID: 23800123 DOI: 10.1111/1475-6773.12079] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To examine the effects of the racial composition of residents on nursing homes' financial and quality performance. The study examined Medicare and Medicaid-certified nursing homes across the United States that submitted Medicare cost reports between the years 1999 and 2004 (11,472 average per year). DATA SOURCE Data were obtained from the Minimum Data Set, the On-Line Survey Certification and Reporting, Medicare Cost Reports, and the Area Resource File. STUDY DESIGN Panel data regression with random intercepts and negative binomial regression were conducted with state and year fixed effects. PRINCIPAL FINDINGS Financial and quality performance differed between nursing homes with high proportions of black residents and nursing homes with no or medium proportions of black residents. Nursing homes with no black residents had higher revenues and higher operating margins and total profit margins and they exhibited better processes and outcomes than nursing homes with high proportions of black residents. CONCLUSION Nursing homes' financial viability and quality of care are influenced by the racial composition of residents. Policy makers should consider initiatives to improve both the financial and quality performance of nursing homes serving predominantly black residents.
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Affiliation(s)
- Latarsha Chisholm
- Department of Health Management and Informatics, University of Central Florida, Orlando, FL
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22
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Ashcraft AS, Champion JD. Nursing home resident symptomatology triggering transfer: avoiding unnecessary hospitalizations. Nurs Res Pract 2012; 2012:495103. [PMID: 23091714 DOI: 10.1155/2012/495103] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Revised: 09/04/2012] [Accepted: 09/04/2012] [Indexed: 11/24/2022] Open
Abstract
The purpose of this study was to describe nursing home resident symptomatology and medical diagnoses associated with nursing home to hospital transfers. A retrospective chart review of documented transfers was conducted at a 120-bed, nonprofit urban Continuing Care Retirement Center nursing home facility located in the southwestern United States. The transferred residents (n = 101) had seventy different medical diagnoses prior to hospital transfer with hypertension, coronary artery disease, and congestive heart failure most frequently reported. Most frequently reported symptomatology included fatigue, lethargy or weakness, shortness of breath, and change in level of consciousness. Multiple symptomatology was indicative of a wide variety of medical diagnoses. The diagnoses and symptomatology recorded in this paper identify the importance of strategic planning concerning assessment and communication of common nursing home resident symptomatology and the importance of basic nursing and diagnostic procedures for prevention of potentially avoidable hospitalizations.
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Schouten HJ, van Ginkel S, Koek H(D, Geersing GJ, Oudega R, Moons KG, van Delden J(H. Non-Diagnosis Decisions and Non-Treatment Decisions in Elderly Patients With Cardiovascular Diseases, Do They Differ? – A Systematic Review. J Am Med Dir Assoc 2012; 13:682-7. [PMID: 22705033 DOI: 10.1016/j.jamda.2012.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 05/14/2012] [Accepted: 05/14/2012] [Indexed: 11/25/2022]
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Song MK, Ward SE, Lin FC. End-of-life decision-making confidence in surrogates of African-American dialysis patients is overly optimistic. J Palliat Med 2012; 15:412-7. [PMID: 22468770 DOI: 10.1089/jpm.2011.0330] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Recent studies suggest that surrogate decision makers may be too optimistic about their end-of-life decision making abilities for loved ones. We examined surrogates' decision making confidence with an emphasis on its linkages to their understandings of patients' values and goals for end-of-life care. METHODS We used baseline data from a randomized trial with 58 dyads of African-American dialysis patients and their surrogates who separately completed the Values of Life-Sustaining Treatment Outcomes and the Goals of Care documents. Surrogates also completed a Surrogate Decision Making Confidence Scale. RESULTS Overall, 60% of surrogates were unsure how their loved ones would feel about continuing life-sustaining treatment, including dialysis, in at least one of the four outcomes presented in the Values of Life-Sustaining Treatment Outcomes. For goals of care near end of life, 67.2% to 69.0% of patients preferred comfort care only, but only 20 (34.5%) surrogates were congruent with patients on Goals of Care. Nonetheless, surrogates' confidence was high (M=3.23 out of 4.0). Surrogates' confidence was positively associated with dyad congruence in values for life-sustaining treatment at only a small magnitude (Spearman's rho=.31, p=.02), but not with dyad congruence in goals of care (χ(2)=2.13, df=1, p=.19). CONCLUSIONS Surrogates' confidence had little association with their actual understanding of patients' values and goals. Interventions to prepare patients and surrogates for end-of-life decision making may need to address overconfidence and help surrogates recognize their limited understanding of patients' values and goals.
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Affiliation(s)
- Mi-Kyung Song
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
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25
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Friedenberg AS, Levy MM, Ross S, Evans LE. Barriers to End-of-Life Care in the Intensive Care Unit: Perceptions Vary by Level of Training, Discipline, and Institution. J Palliat Med 2012; 15:404-11. [DOI: 10.1089/jpm.2011.0261] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Allison S. Friedenberg
- Department of Medicine, Santa Clara Valley Medical Center, Stanford School of Medicine, San Jose, California
| | - Mitchell M. Levy
- Department of Nursing, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Susan Ross
- Department of Nursing, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Laura E. Evans
- Department of Medicine, New York University School of Medicine, New York, New York
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Zheng NT, Mukamel DB, Caprio T, Cai S, Temkin-Greener H. Racial disparities in in-hospital death and hospice use among nursing home residents at the end of life. Med Care 2011; 49:992-8. [PMID: 22002648 DOI: 10.1097/MLR.0b013e318236384e] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Significant racial disparities have been reported regarding nursing home residents' use of hospital and hospice care at the end of life (EOL). OBJECTIVE To examine whether the observed racial disparities in EOL care are due to within-facility or across-facility variations. RESEARCH DESIGN AND SUBJECTS Cross-sectional study of 49,048 long-term care residents (9.23% black and 90.77% white) in 555 New York State nursing homes who died during 2005-2007. The Minimum Data Set was linked with Medicare inpatient and hospice claims. MEASURES In-hospital death determined by inpatient claims and hospice use determined by hospice claims. For each outcome, risk factors were added sequentially to examine their partial effects on the racial differences. Hierarchical models were fit to test whether racial disparities are due to within-facility or across-facility variations. RESULTS 40.33% of blacks and 24.07% of whites died in hospitals; 11.55% of blacks and 17.39% of whites used hospice. These differences are partially due to disparate use of feeding tubes, do-not-resuscitate and do-not-hospitalize orders. We find no racial disparities in in-hospital death [odds ratio (OR) of race=0.95; 95% confidence interval (CI), 0.87-1.04] or hospice use (OR of race=0.90, 95% CI, 0.79-1.02) within same facilities. Living in facilities with 10% more blacks increases the odds of in-hospital death by 22% (OR=1.22, 95% CI, 1.17-1.26) and decreases the odds of hospice use by 15% (OR=0.85, 95% CI, 0.78-0.94). CONCLUSIONS Differential use of feeding tubes, do-not-resuscitate and do-not-hospitalize orders lead to racial differences in in-hospital death and hospice use. The remaining disparities are primarily due to overall EOL care practices in predominately black facilities, not to differential hospitalization and hospice-referral patterns within facilities.
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Bossuyt N, Van den Block L, Cohen J, Meeussen K, Bilsen J, Echteld M, Deliens L, Van Casteren V. Is individual educational level related to end-of-life care use? Results from a nationwide retrospective cohort study in Belgium. J Palliat Med 2011; 14:1135-41. [PMID: 21815816 DOI: 10.1089/jpm.2011.0045] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Educational level has repeatedly been identified as an important determinant of access to health care, but little is known about its influence on end-of-life care use. OBJECTIVES To examine the relationship between individual educational attainment and end-of-life care use and to assess the importance of individual educational attainment in explaining differential end-of-life care use. RESEARCH DESIGN A retrospective cohort study via a nationwide sentinel network of general practitioners (GPs; SENTI-MELC Study) provided data on end-of-life care utilization. Multilevel analysis was used to model the association between educational level and health care use, adjusting for individual and contextual confounders based upon Andersen's behavioral model of health services use. SUBJECTS A Belgian nationwide representative sample of people who died not suddenly in 2005-2007. RESULTS In comparison to their less educated counterparts, higher educated people equally often had a palliative treatment goal but more often used multidisciplinary palliative care services (odds ratios [OR] for lower secondary education 1.28 [1.04-1.59] and for higher [secondary] education: 1.31 [1.02-1.68]), moved between care settings more frequently (OR: 1.68 [1.13-2.48] for lower secondary education and 1.51 [0.93-2.48] for higher [secondary] education) and had more contacts with the GP in the final 3 months of life. CONCLUSIONS Less well-educated people appear to be disadvantaged in terms of access to specialist palliative care services, and GP contacts at the end of life, suggesting a need for empowerment of less well-educated terminally ill people regarding specialist palliative and general end-of-life care use.
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Affiliation(s)
- Nathalie Bossuyt
- Scientific Institute of Public Health, Operational Directorate Public Health & Surveillance, Brussels, Belgium.
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Ryvicker M. Staff–resident interaction in the nursing home: An ethnographic study of socio-economic disparities and community contexts. J Aging Stud 2011; 25:295-304. [DOI: 10.1016/j.jaging.2010.11.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Parikh S, Brookhart MA, Stedman M, Avorn J, Mogun H, Solomon DH. Correlations of nursing home characteristics with prescription of osteoporosis medications. Bone 2011; 48:1164-8. [PMID: 21320653 PMCID: PMC3096758 DOI: 10.1016/j.bone.2011.02.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 01/18/2011] [Accepted: 02/06/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Osteoporosis is highly prevalent in the nursing home (NH) populations but medications that increase bone mineral density are used infrequently. Prior research finds few patient characteristics predict treatment. NH characteristics have been associated with prescription of some medications. We examined associations of NH-level characteristics with osteoporosis treatment in elderly patients admitted to a NH after a fracture. METHOD We conducted a cohort study of patients with hip, wrist and humeral fractures admitted to a NH in NJ. They were followed for 12 months from 1999 to 2004. Possible NH-level predictors of receiving osteoporosis treatment were assessed in mixed multivariable models to account for clustering within individual NHs. RESULTS Of the 2838 post-fracture patients identified from 180 NHs, 156 (5.5%) were prescribed an osteoporosis medication. There was wide variation in treatment between individual NHs (0-40%), which was substantially reduced after adjusting for patient case mix. Several patient characteristics did associate with osteoporosis treatment-female gender (odds ratio (OR) 2.56, 95% confidence interval (CI) 1.42, 4.61), younger age per year (OR 0.98, 95%CI 0.96, 0.99), white race (OR 2.37, 95%CI 1.23, 4.56) and prior history of fracture (OR 4.41, 95%CI 1.04, 18.73). However no NH characteristics significantly associate with treatment (profit status, NH chain member, occupancy rate, and bed size). CONCLUSION NH characteristics did not predict pharmacological treatment of osteoporosis. Further studies of osteoporosis prescribing in NHs need to consider other types of variables as possible correlates of prescribing.
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Affiliation(s)
- Seema Parikh
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Womens’ Hospital and Harvard Medical School, Suite 3030 1640 Tremont St, Boston, MA
- Division of Gerontology, Lowry Medical Office Building, Suite 1B, Beth Israel Deaconess Medical Center 110 Francis St, Boston MA 02215
- Division of Rheumatology, Brigham and Womens’ Hospital, 75 Francis St Boston, MA 02115
| | - M. Alan Brookhart
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Womens’ Hospital and Harvard Medical School, Suite 3030 1640 Tremont St, Boston, MA
| | - Margaret Stedman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Womens’ Hospital and Harvard Medical School, Suite 3030 1640 Tremont St, Boston, MA
| | - Jerry Avorn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Womens’ Hospital and Harvard Medical School, Suite 3030 1640 Tremont St, Boston, MA
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Womens’ Hospital and Harvard Medical School, Suite 3030 1640 Tremont St, Boston, MA
| | - Daniel H Solomon
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Womens’ Hospital and Harvard Medical School, Suite 3030 1640 Tremont St, Boston, MA
- Aged Care Services, Caulfield General Medical Center, 260 Kooyong Road, Caulfield, Victoria, Australia 3162
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Lepore MJ, Miller SC, Gozalo P. Hospice use among urban Black and White U.S. nursing home decedents in 2006. Gerontologist 2011; 51:251-60. [PMID: 21076085 PMCID: PMC3058130 DOI: 10.1093/geront/gnq093] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Accepted: 10/12/2010] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Medicare hospice is a valuable source of quality care at the end of life, but its lower use by racial minority groups is of concern. This study identifies factors associated with hospice use among urban Black and White nursing home (NH) decedents in the United States. DESIGN AND METHODS Multiple data sources are combined and multilevel logistic regression is utilized to examine hospice use among urban Black and White NH residents who had access to hospice and died in 2006 (N = 288,202). RESULTS In NHs, Blacks are less likely to use hospice than Whites (35.4% vs. 39.3%), even when controlling for covariates, interactions, and clustering of decedents in NHs and counties (adjusted odds ratio = 0.81, 95% confidence interval = 0.77-0.86). Variation in hospice use is greater among subgroups of Blacks than between Blacks and Whites, and these variations are predominantly due to individual-level factors, with some influence of NH-level factors. Hospice use is higher for Blacks versus Whites with do-not-resuscitate orders and lower for Blacks versus Whites with congestive heart failure (CHF). Additionally, hospice use is greater among Blacks with versus without do-not-resuscitate or do-not-hospitalize orders or cancer and those in low-tier versus other NHs. There was also lower hospice use among Blacks with versus without CHF. IMPLICATIONS Efforts to reduce racial differences in hospice use should attend to individual-level factors. Heightening use of advance directives and targeting Blacks with CHF for hospice could be particularly helpful.
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Affiliation(s)
- Michael J Lepore
- Department of Community Health, Center for Gerontology and Health Care Research, Brown University, Providence, RI 02912, USA.
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Abstract
OBJECTIVES We examined racial disparities in rehospitalization rates among a cohort of non-Hispanic White and Black Medicare beneficiaries admitted to skilled nursing facilities for postacute care. METHODS We analyzed the 2008 national Nursing Home Minimum Data Set, augmented with other databases. We used multivariable logistic regression to estimate overall racial disparities in rehospitalization rates within 30 days and 90 days of nursing facility admission and the extent to which the disparities were explained by patient, facility, market, and state factors. Stratified analyses identified persistent disparities within patient subgroups, facility types, and states. RESULTS The 30-day rehospitalization rates were 14.3% for White patients (n = 865 993) and 18.6% for Black patients (n = 94 651); the 90-day rehospitalization rates were 22.1% and 29.5%, respectively. Both patient and admitting facility characteristics accounted for a considerable portion of overall racial disparities, but disparities persisted after multivariable adjustments overall and in patient subgroups. CONCLUSIONS We found persistent racial disparities in rehospitalization among the nation's skilled nursing facility patients receiving postacute care. Targeted efforts are needed to remove these disparities.
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Affiliation(s)
- Yue Li
- Division of General Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, 52242, USA.
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Modi S, Velde B, Gessert CE. Perspectives of community members regarding tube feeding in patients with end-stage dementia: findings from African-American and Caucasian focus groups. Omega (Westport) 2011; 62:77-91. [PMID: 21138071 DOI: 10.2190/om.62.1.d] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Research has demonstrated that placement of permanent feeding tubes to provide artificial nutrition is more common among non-white populations, but there is a scarcity of research regarding why those differences may exist. The purpose of this study is to describe and understand community members' attitudes toward tube feeding and end-of-life decision-making. Four focus groups were convened in Greenville, NC. The 28 focus group participants were 11 African American and 17 Caucasian community members between ages 51 and 81. Two focus groups were held with Caucasian participants and two with African-American participants. Focus groups were recorded and transcribed, and qualitative analysis was performed using NVivo software. Seven themes resulted from the analysis of the transcripts. They included: "A feeding tube is," "Food is important," "They want to do the right thing," "To make a rational decision," "There are worse things than death," "There's a lot of good things," "It's out of my hands." There were more commonalities than differences in the views of African Americans and Caucasians on perspectives on tube feeding and elders with dementia. An unexpected emphasis was placed on the importance of food as a symbol of caring. Families tend to be oriented toward personal fidelity to the elder and the symbolic role of feeding in fulfilling that fidelity.
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Davies B, Larson J, Contro N, Cabrera AP. Perceptions of discrimination among Mexican American families of seriously ill children. J Palliat Med 2011; 14:71-6. [PMID: 21194301 PMCID: PMC3021359 DOI: 10.1089/jpm.2010.0315] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2010] [Indexed: 11/12/2022] Open
Abstract
This paper describes Mexican American family members' descriptions of perceived discrimination by pediatric health care providers (HCPs) and the families' reactions to the HCPs' discriminatory conduct. A retrospective, grounded theory design guided the overall study. Content analysis of interviews with 13 participants from 11 families who were recruited from two children's hospitals in Northern California resulted in numerous codes and revealed that participants perceived discrimination when they were treated differently from other, usually white, families. They believed they were treated differently because they were Mexican, because they were poor, because of language barriers, or because of their physical appearance. Participants reported feeling hurt, saddened, and confused regarding the differential treatment they received from HCPs who parents perceived "should care equally for all people." They struggled to understand and searched for explanations. Few spoke up about unfair treatment or complained about poor quality of care. Most assumed a quiet, passive position, according to their cultural norms of respecting authority figures by being submissive and not questioning them. Participants did not perceive all HCPs as discriminatory; their stories of discrimination derived from encounters with individual nurses or physicians. However, participants were greatly affected by the encounters, which continue to be painful memories. Despite increasing efforts to provide culturally competent palliative care, there is still need for improvement. Providing opportunities for changing HCPs' beliefs and behaviors is essential to developing cultural competence.
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Affiliation(s)
- Betty Davies
- Family Health Care Nursing, University of California San Francisco, San Francisco, California, USA.
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Zheng NT, Temkin-Greener H. End-of-life care in nursing homes: the importance of CNA staff communication. J Am Med Dir Assoc 2010; 11:494-9. [PMID: 20816337 DOI: 10.1016/j.jamda.2010.01.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Revised: 01/12/2010] [Accepted: 01/14/2010] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Staff communication has been shown to influence overall nursing home (NH) performance. However, no empirical studies have focused specifically on the impact of CNA communication on end-of-life (EOL) care processes. This study examines the relationship between CNA communication and nursing home performance in EOL care processes. DESIGN Secondary data analysis of 2 NH surveys conducted in 2006-2007. SETTING One hundred seven nursing homes in New York State. PARTICIPANTS Participants were 2636 CNAs and 107 directors of nursing (DON). MEASUREMENTS The measures of EOL care processes-EOL assessment and care delivery (5-point Likert scale scores)-were obtained from survey responses provided by 107 DONs. The measure of CNA communication was derived from survey responses obtained from 2636 CNAs. Other independent variables included staff education, hospice use intensity, staffing ratio, staff-resident ethnic overlap index, facility religious affiliation, and ownership. METHODS The reliability and validity of the measures of EOL care processes and CNA communication were tested in the current study sample. Multivariate linear regression models with probability weights were used. The analysis was conducted at the facility level. RESULTS We found better CNA communication to be significantly associated with better EOL assessment (P = .043) and care delivery (P = .098). Two potentially modifiable factors-staff education and hospice use intensity-were associated with NHs' performance in EOL care processes. Facilities with greater ethnic overlap between staff and residents demonstrated better EOL assessment (P = .051) and care delivery scores (P = .029). CONCLUSION Better CNA communication was associated with better performance in EOL care processes. Our findings provide specific insights for NH leaders striving to improve EOL care processes and ultimately the quality of care for dying residents.
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Affiliation(s)
- Nan Tracy Zheng
- Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA.
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Kind AJH, Smith MA, Liou JI, Pandhi N, Frytak JR, Finch MD. Discharge destination's effect on bounce-back risk in Black, White, and Hispanic acute ischemic stroke patients. Arch Phys Med Rehabil 2010; 91:189-95. [PMID: 20159120 DOI: 10.1016/j.apmr.2009.10.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 09/24/2009] [Accepted: 10/20/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine whether racial and ethnic effects on bounce-back risk (ie, movement to settings of higher care intensity within 30 d of hospital discharge) in acute stroke patients vary depending on initial posthospital discharge destination. DESIGN Retrospective analysis of administrative data. SETTING Four hundred twenty-two hospitals, southern/eastern United States. PARTICIPANTS All Medicare beneficiaries 65 years or more with hospitalization for acute ischemic stroke within one of the 422 target hospitals during the years 1999 or 2000 (N=63,679). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Adjusted predicted probabilities for discharge to and for bouncing back from each initial discharge site (ie, home, home with home health care, skilled nursing facility [SNF], or rehabilitation center) by race (ie, black, white, and Hispanic). Models included sociodemographics, comorbidities, stroke severity, and length of stay. RESULTS Blacks and Hispanics were significantly more likely to be discharged to home health care (blacks=21% [95% confidence interval (CI), 19.9-22.8], Hispanic=19% [17.1-21.7] vs whites=16% [15.5-16.8]) and less likely to be discharged to SNFs (blacks=26% [95% CI, 23.6-29.3], Hispanics=28% [25.4-31.6] vs whites=33% [31.8-35.1]) than whites. However, blacks and Hispanics were significantly more likely to bounce back when discharged to SNFs than whites (blacks=26% [95% CI, 24.2-28.6], Hispanics=28% [24-32.6] vs whites=21% [20.3-21.9]). Hispanics had a lower risk of bouncing back when discharged home than either blacks or whites (Hispanics=14% [95% CI, 11.3-17] vs blacks=20% [18.4-22.2], whites=18% [16.8-18.3]). Patients discharged to home health care or rehabilitation centers demonstrated no significant differences in bounce-back risk. CONCLUSIONS Racial/ethnic bounce-back risk differs depending on initial discharge destination. Additional research is needed to fully understand this variation in effect.
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Affiliation(s)
- Amy J H Kind
- Department of Medicine-Geriatrics Section, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, USA.
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Abstract
PURPOSE The objectives of this study were to develop measures of end-of-life (EOL) care processes in nursing homes and to validate the instrument for measuring them. DESIGN AND METHODS A survey of directors of nursing was conducted in 608 eligible nursing homes in New York State. Responses were obtained from 313 (51.5% response rate) facilities. Secondary data on structural characteristics of the nursing homes were obtained from the Online Survey Certification and Reporting System. Exploratory factor analyses and internal consistency reliability analyses were performed. Multivariate regression models with fixed and random effects were estimated. RESULTS Four EOL process domains were identified-assessment, delivery, communication and coordination of care among providers, and communication with residents and families. The scales measuring these EOL process domains demonstrated acceptable to high internal consistency reliability and face, content, and construct validity. Facilities with more EOL quality assurance or monitoring mechanisms in place and greater emphasis on EOL staff education had better scores on EOL care processes of assessment, communication and coordination among providers, and care delivery. Facilities with better registered nurse and certified nurse aide staffing ratios and those with religious affiliation also scored higher on selected care process measures. IMPLICATIONS This study offers a new validated tool for measuring EOL care processes in nursing homes. Our findings suggest wide variations in care processes across facilities, which in part may stem from lack of gold standards for EOL practice in nursing homes.
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Affiliation(s)
- Helena Temkin-Greener
- Department of Community and Preventive Medicine, Center for Ethics, Humanities and Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA.
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Gruneir A, Miller SC, Feng Z, Intrator O, Mor V. Relationship between state medicaid policies, nursing home racial composition, and the risk of hospitalization for black and white residents. Health Serv Res 2008; 43:869-81. [PMID: 18454772 DOI: 10.1111/j.1475-6773.2007.00806.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine racial differences in the risk of hospitalization for nursing home (NH) residents. DATA SOURCES National NH Minimum Data Set, Medicare claims, and Online Survey Certification and Reporting data from 2000 were merged with independently collected Medicaid policy data. STUDY DESIGN One hundred and fifty day follow-up of 516,082 long-stay residents. PRINCIPLE FINDINGS 18.5 percent of white and 24.1 percent of black residents were hospitalized. Residents in NHs with high concentrations of blacks had 20 percent higher odds (95 percent confidence interval [CI]=1.15-1.25) of hospitalization than residents in NHs with no blacks. Ten-dollar increments in Medicaid rates reduced the odds of hospitalization by 4 percent (95 percent CI=0.93-1.00) for white residents and 22 percent (95 percent CI=0.69-0.87) for black residents. CONCLUSIONS Our findings illustrate the effect of contextual forces on racial disparities in NH care.
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Affiliation(s)
- Andrea Gruneir
- Kunin-Lunenfeld Applied Research Unit, Baycrest Centre for Geriatric Care, Toronto, ON M6A 2E1, Canada
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Kwak J, Haley WE, Chiriboga DA. Racial differences in hospice use and in-hospital death among Medicare and Medicaid dual-eligible nursing home residents. Gerontologist 2008; 48:32-41. [PMID: 18381830 DOI: 10.1093/geront/48.1.32] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE We investigated the role of race in predicting the likelihood of using hospice and dying in a hosptial among dual-eligible (Medicare and Medicaid) nursing home residents. DESIGN AND METHODS This follow-back cohort study examined factors associated with hospice use and in-hospital death among non-Hispanic Black and non-Hispanic White dual-eligible nursing home residents (N = 30,765) who died in Florida during one of three years: 2000, 2001, or 2002. We used logistic regression models to identify independent predictors of hospice use and in-hospital death. RESULTS After we controlled for other factors, Black residents were significantly less likely to use hospice and more likely to die in a hospital. Principal cause of death moderated the relationship between race and hospice use: Black residents were significantly less likely to use hospice than White residents among residents without cancer as principal cause of death, but there was no difference among residents with cancer as cause of death. Further analyses for each racial group revealed that the impact of cause of death in predicting hospice use was greater among Black residents than White residents. IMPLICATIONS Hospice care offers many benefits, including reduced risk of in-hospital death, but Black nursing home residents are less likely to use hospice and may have different perceptions of need for hospice care compared with White residents. Future research and outreach efforts should focus on developing culturally sensitive, disease-focused end-of-life education and communication interventions that target residents, families, nursing home providers, and physicians.
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Affiliation(s)
- Jung Kwak
- Center on Age and Community/Applied Gerontology, University of Wisconsin, Milwaukee, Enderis Hall 1055, P.O. Box 786, Milwaukee, WI 53201, USA.
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Abstract
Hospitalization of nursing home residents is costly and potentially exposes residents to iatrogenic disease and psychological harm. This article critically reviews the association between the decision to hospitalize and factors related to the residents' welfare and preferences, the providers' attitudes, and the financial implications of hospitalization. Regarding the resident's welfare, factors associated with hospitalization included sociodemographics, health characteristics, nurse staffing, the presence of ancillary services, and the use of hospices. Patient preferences (e.g., advance directives) and provider attitudes (e.g., overburdening of staff) were also associated with increased hospitalization. Finally, financial variables related to hospitalization included nursing home ownership status and state Medicaid policies, such as nursing home payment rates and bed-hold requirements. Most studies relied on potentially confounded research designs, which leave open the issue of selection bias. Nevertheless, the existing literature asserts that nursing home hospitalizations are frequent, often preventable, and related to facility practices and state Medicaid policies.
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Rodin MB. Cancer Patients Admitted to Nursing Homes: What Do We Know? J Am Med Dir Assoc 2008; 9:149-56. [DOI: 10.1016/j.jamda.2007.11.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2007] [Revised: 11/28/2007] [Accepted: 11/28/2007] [Indexed: 10/22/2022]
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Cukor D, Cohen SD, Peterson RA, Kimmel PL. Psychosocial Aspects of Chronic Disease: ESRD as a Paradigmatic Illness. J Am Soc Nephrol 2007; 18:3042-55. [DOI: 10.1681/asn.2007030345] [Citation(s) in RCA: 248] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Abstract
OBJECTIVE To examine the patient, nursing home (NH), hospice provider, and local market factors associated with the selection of the Medicare hospice benefit by eligible NH residents, and evaluate the causal effect of hospice on end-of-life hospitalization rates. DATA SOURCES/STUDY SETTING Secondary data for 1995-1997 for NH residents. STUDY DESIGN This retrospective cohort study includes NH residents in five states (Kansa, Maine, New York, Ohio, South Dakota) who died in the years 1995-1997. Medicare claims identified hospice enrollment and hospitalizations. Geocoding of NHs, hospice providers, and hospitals was used to identify local markets. The two outcome measures are hospice enrollment and hospitalization of NH residents in their last 30 days of life. DATA COLLECTION/EXTRACTION METHOD A file was constructed linking MDS assessments to Medicare claims and denominator files, NH provider files (OSCAR), hospice provider of service files, and the area resource file. PRINCIPAL FINDINGS Twenty-six percent of hospice and 44 percent of nonhospice residents were hospitalized in their last 30 days of life (odds ratio [OR] 0.45; 95 percent confidence interval [CI]: 0.42-0.48). Adjusting for confounders, hospice patients were less likely than nonhospice residents to be hospitalized (OR 0.47; 95 percent CI: 0.45-0.50). Adding inverse propensity score weighting, hospice patients were still less likely than nonhospice residents to be hospitalized (OR 0.56; 95 percent CI: 0.53-0.61). CONCLUSIONS Hospice selection introduces some bias in the evaluation of the causal effect of hospice on end-of-life hospitalization rates. However, even after adjusting for selection bias, hospice does have a powerful effect in reducing end-of-life hospitalization rates.
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Affiliation(s)
- Pedro L Gozalo
- Center for Gerontology and Health Care Research, Department of Community Health, Brown University School of Medicine, Box G-ST211, 2 Stimson Street, Providence, RI 02912, USA
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Miller SC, Papandonatos G, Fennell M, Mor V. Facility and county effects on racial differences in nursing home quality indicators. Soc Sci Med 2006; 63:3046-59. [PMID: 16997439 DOI: 10.1016/j.socscimed.2006.08.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2005] [Indexed: 11/17/2022]
Abstract
This study's goal was to examine the effects of nursing home (NH) and county racial mix on quality of care in NHs. We examined quality indicator (QI) outcomes for residents in 408 urban New York NHs in July through September, 1995. The QI outcomes studied were restraint and antipsychotic drug use (for low and high-risk residents), and at study commencement, these QIs were being used by the Centers for Medicare and Medicaid Services to monitor the quality of care in USA Medicare and/or Medicaid-certified NHs. A hierarchical modeling approach was used to properly reflect the nesting of both residents within NHs and NHs within counties. Separate regression models were fit to the two strata of interest (Urban Non-Hispanic Whites and Urban African Americans) to test, for each race group, the effect on quality of residing in NHs and counties with higher proportions of African Americans (than state medians). Descriptive analyses found that, compared to Whites, the unadjusted restraint rate was lower for African Americans while the antipsychotic drug rate was higher. For both race groups, multi-level analyses showed residence in for-profit NHs was associated with higher likelihoods of being restrained, and of receiving antipsychotic drugs. Also, for both race groups, residence in NHs with higher proportions of African-Americans was associated with lower likelihoods of being restrained and with higher, statistically nonsignificant, likelihoods of receiving antipsychotic drugs. Higher NH nurse staffing ratios were associated with higher likelihoods of being restrained and with lower likelihoods of antipsychotic drug use (statistically significant for low-risk African-Americans). Findings support the notion that differential care is provided in USA NHs caring for higher proportions of African-American residents and thereby suggest intervention at the organizational level is warranted to improve QI outcomes for both race groups.
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