End-of-Life Transitions among Nursing Home Residents with Cognitive Issues
Open accessAbstract
BACKGROUND: Health care transitions in the last months of life can be burdensome and potentially of limited clinical benefit for patients with advanced cognitive and functional impairment. METHODS: To examine health care transitions among Medicare decedents with advanced cognitive and functional impairment who were nursing home residents 120 days before death, we linked nationwide data from the Medicare Minimum Data Set and claims files from 2000 through 2007. We defined patterns of transition as burdensome if they occurred in the last 3 days of life, if there was a lack of continuity in nursing homes after hospitalization in the last 90 days of life, or if there were multiple hospitalizations in the last 90 days of life. We also considered various factors explaining variation in these rates of burdensome transition. We examined whether there was an association between regional rates of burdensome transition and the likelihood of feeding-tube insertion, hospitalization in an intensive care unit (ICU) in the last month of life, the presence of a stage IV decubitus ulcer, and hospice enrollment in the last 3 days of life. RESULTS: Among 474,829 nursing home decedents, 19.0% had at least one burdensome transition (range, 2.1% in Alaska to 37.5% in Louisiana). In adjusted analyses, blacks, Hispanics, and those without an advance directive were at increased risk. Nursing home residents in regions in the highest quintile of burdensome transitions (as compared with those in the lowest quintile) were significantly more likely to have a feeding tube (adjusted risk ratio, 3.38), have spent time in an ICU in the last month of life (adjusted risk ratio, 2.10), have a stage IV decubitus ulcer (adjusted risk ratio, 2.28), or have had a late enrollment in hospice (adjusted risk ratio, 1.17). CONCLUSIONS: Burdensome transitions are common, vary according to state, and are associated with markers of poor quality in end-of-life care.
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Nursing home residents frequently have burdensome transitions at the end of life, including ICU admission in the last month of life and late hospice enrollment.
“Other researchers have shown that nursing home residents frequently have burdensome transitions at the end of life, including admission to an intensive care unit in the last month of life and late enrollment in hospice, 751”
From 2023 Alzheimer's disease facts and figures (2023) · cites this paper as [751]
The Abstract Results report that 19.0% of nursing home decedents with advanced cognitive and functional impairment had a burdensome transition. The Methods and Results treat ICU admission in the last month of life and late hospice enrollment as separate markers of poor end-of-life care associated with burdensome transitions, not as transitions included in their definition. The claim also omits the study population’s impairment qualifier. (LLM, conf=0.86)
Experimental — accuracy not yet measuredNursing home residents frequently have burdensome transitions at the end of life, including admission to an intensive care unit in the last month of life and late enrollment in hospice.
“Other researchers have shown that nursing home residents frequently have burdensome transitions at the end of life, including admission to an intensive care unit in the last month of life and late enrollment in hospice, 902”
From 2024 Alzheimer's disease facts and figures (2024) · cites this paper as [902]
The Results report that 19.0% of the studied nursing home decedents had a burdensome transition, and that 9.1% spent time in an ICU in the last 30 days of life while 6.1% were referred to hospice in the last 3 days. However, the Methods classify certain transfers and hospitalizations as burdensome transitions; ICU stays and late hospice enrollment are separate markers of poor end-of-life care associated with transition rates, not examples in that classification. The study also concerns residents with advanced cognitive and functional impairment, rather than nursing home residents generally. (LLM, conf=0.89)
Experimental — accuracy not yet measuredTotal spending on home care for Medicare beneficiaries with Alzheimer's or other dementias increased dramatically between 2004 and 2018.
“Additionally, total spending on home care for Medicare beneficiaries with Alzheimer's or other dementias increased dramatically between 2004 and 2018.902”
From 2024 Alzheimer's disease facts and figures (2024) · cites this paper as [902]
The Methods (Study Population; page unavailable) say the paper used Medicare data from 2000 through 2007 to study end-of-life transitions among nursing home residents. The Discussion mentions hospitalization costs, but the searched passages do not report total home-care spending for beneficiaries with dementia or a change between 2004 and 2018. (LLM, conf=0.77)
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- Authors
- Gozalo, P., Teno, J. M., Mitchell, S. L., Skinner, J., Bynum, J., Tyler, D., & Mor, V.
- Affiliations
- Brown University (US)
- Hebrew SeniorLife (US)
- Dartmouth Institute for Health Policy and Clinical Practice (US)
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2011-09-29
- Volume
- 365
- Issue
- 13
- Pages
- 1212-1221
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- PMC
- PMC3236369
- OpenAlex
- W2013203952
- Cited by
- 484
- References
- 39
- Citations by year
- 2026: 22 · 2025: 20 · 2024: 27 · 2023: 27 · 2022: 45 · 2021: 43 · 2020: 37 · 2019: 43 · 2018: 34 · 2017: 49 · 2016: 34 · 2015: 26 · 2014: 34 · 2013: 22 · 2012: 20
- FWCI
- 23.91
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institutes of Health (2p01ag027296-16)
- National Institute on Aging (P01AG-027296, K24AG033640)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Keywords
- end-of-life care, nursing home residents, care transitions, functional disability, feeding tube, intensive care unit, pressure ulcers, hospice enrollment, advance directives, racial disparities, regional variation, quality of end-of-life care
- MeSH terms
- Aged, Aged, 80 and over, Cognition Disorders, Continuity of Patient Care, Female, Medicare, Hospitalization, Humans, Male, Nursing Homes, Patient Transfer, Quality of Health Care, Terminal Care, United States
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