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About 20% of nursing home residents with advanced dementia experience burdensome transitions near the end of life.

About 20% of nursing home residents with advanced dementia experience burdensome transitions near the end of life.

Critique date: Wed, 01/18/2012 - 11:40am
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Institution: 
Mount Sinai School of Medicine
   
Article Citation
Citation: 
Gozalo P, Teno JM, Mitchell SL, Skinner J, Bynum J, Tyler D, Mor V. End-of-life transitions among nursing home residents with cognitive issues. N Engl J Med. 2011, 365(13):1212-21.
   
Clinical Bottom Lines

Nationally about 20% of nursing home patients with advanced cognitive issues experience burdensome transitions which are defined as any transfer in last 3 days of life, lack of continuity of facility in last 90 days or multiple hospitalizations in last 90 days.

There exists broad regional variation observed by state.

When patients in high burdensome transition zones are compared to low zones, the former was more likely to experience poor quality end-of-life care as defined by the rate of several different complications near end of life.  

Disclaimer: 
This is a review of the validity of a single study; the ‘bottom lines’ do not reflect comparison with the rest of the literature on this subject.
   
Methods
Type of Study: 
Harm
Study Design: 
Cohort study
Follow-up Period: 
not applicable to this study
Setting: 
nursing home
Patient Population: 

Patient information was derived from the Medicare Minimal Data Set. Medicare decedents with the following characteristics were included: residing in nursing home 120 days before death, older than 66 years old, total dependence in all 7 activities of daily living and advanced cognitive impairment. Degree of cognitive impairment was assessed using the cognitive performance score and study included patients with scores of 5-6 (severe to very severe impairment) which corresponds to MMSE mean score of 5.1.

According to table 1, of 474,829 nursing home decedents studied, the mean age of study patients was 85.7 years old. 78% of patients were female and the majority of patients were white (83%) and had only high school or less than high school education (31.2 + 37.9 = 69.1%). 73% of patients had a do-not-resuscitate order but only 6.8% had a do-not-hospitalize order.

Significant Exclusions: 

There were no cited exclusion criteria. All available patient data was used in analysis. Less than 1% of patients had missing data regarding advanced directives.

Intervention/Exposure: 

Not applicable to this study (retrospective cohort study of outcome at end of life of Medicare decedents).

Outcome Measures: 

In the first part of the study, the authors examined the frequency of burdensome transitions which was defined as:

(1) any transfer in last 3 days of life

(2) lack of continuity of facility in last 90 days (defined as going from one nursing home to hospital to another nursing home at discharge)

(3) multiple hospitalizations in last 90 days (defined as either more than 2 hospitalizations for any reason or more than 1 hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis).


In the second part of the study, the authors perform a harm analysis to assess the risk of presence of markers of poor quality end-of-life care patients in regions with high burdensome transitions compared with low transition regions. Markers of poor quality were defined as:

(1) feeding tube insertions

(2) admissions to ICU in last 30 days

(3) enrollment in hospital in last 3 days

(4) presence of stage IV decubitus ulcers

Participant Follow-up: 
Not applicable to this study
   
Results
Results: 

Using the Medicare Minimal Data Set, this article describes the frequency of burdensome transitions from nursing home to other care settings for patients with advanced cognitive issues (corresponding to cognitive performance scale of 5-6 or MMSE mean score of 5.1) at the end of life.

Nationally, about 20% of these patients experience burdensome transitions as defined above.

There is broad regional variation observed by state of at least one burdensome transition, with Alaska with lowest percentage (2%) and Louisiana (37%). In general, these transitions were more common in the South, California, New York and New Jersey, and less common in the Northwest, New England and Alaska.

When patients in high burdensome transition zones are compared to low zones, the former was more likely to experience poor quality end-of-life care as defined by the rate of (1) feeding tube insertions (adjusted risk ratio 3.38), (2) admissions to ICU in last 30 days (adjusted risk ratio 2.10), (3) enrollment in hospice in last 3 days (adjusted risk ratio 1.17) or (4) presence of stage IV decubitus ulcers (adjusted risk ratio 2.28). 

   
Methodological Issues…
Methodological Issues and Applicability to Older Adults: 

The concept of  “burdensome transitions”  was created for this study and these particular transitions have not been grouped together for study elsewhere. Whether these transitions are truly burdensome may depend on patient and physician preferences for care. Decedent studies are limited by the fact that patients with similar characteristics who did not die are excluded from study.

   
Other Information
Funding Source and Role: 
National Institute on Aging
Created By: 
Catherine V. Laiosa, MD, PhD, Fellow, Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine

Disclaimer: This is a review of the validity of a single study; the ‘bottom lines’ do not reflect comparison with the rest of the literature on this subject.