Multiple hospitalizations for complications from a terminal illness may be burdensome for elderly patients and reflect poor quality care. Infections and eating problems are 2 such complications characterizing the final stage of dementia.1
In a previous study,1 burdensome health care transitions were defined as 2 or more hospitalizations for infections or dehydration during the last 90 days of life in nursing home (NH) residents with advanced cognitive impairment. The objective of this study was to examine a related issue: whether the occurrence of multiple hospitalizations for these complications was associated with survival.
Methods
The study population was identified using data from the national Minimum Data Set repository,2 which includes standardized assessments regularly completed by staff on all NH residents in the United States between January 1, 2000, and December 31, 2008. We identified the first baseline assessment in which a resident had a Cognitive Performance Score3 of 4, 5, or 6, indicating moderate to very severe cognitive impairment.
We excluded residents who did not survive 30 days beyond the date of this baseline assessment. We followed up the remaining residents for 1 year from the baseline assessment date (through 2009) and identified those who had 2 or more hospitalizations for the same type of the following diagnoses: pneumonia, urinary tract infection (UTI), septicemia, or dehydration or malnutrition. Hospitalizations for these conditions were ascertained from Medicare inpatient claims and based on International Classification of Diseases, Ninth Revision codes.
Cox proportional hazards models were used to describe survival for the residents who had multiple hospitalizations based on the discharge date of the first (index) hospitalization. For comparison, we generated a survival curve in the absence of these complications using a competing risk model. This model examines the overall survival of NH residents accounting for the contributions of persons with 2 or more of these complications to overall survival up to the point of the second complication, when they are censored.
Median survival time was based on these risk-adjusted models for age, sex, race/ethnicity, Cognitive Performance Score, activities of daily living score, the Changes in Health, End-stage disease, Symptoms and Signs scale score,4 and the presence of a do-not-resuscitate order. Race/ethnicity was based on the Minimum Data Set assessment. The institutional review board at Brown University approved this research with waiver of consent. Analyses were performed using Stata version 12 (StataCorp).5
Results
Between 2000 and 2008, 1.3 million NH residents (mean [SD] age, 84.5 [7.5] years; 71.2% were female; 10.2% were black) attained a Cognitive Performance Score of 4, 5, or 6 and survived at least 30 days after that assessment. During the course of 1 year, there were 2 or more hospitalizations for pneumonia in 1.78% (95% CI, 1.76%–1.81%); UTI in 4.33% (95% CI, 4.29%–4.37%); septicemia in 1.58% (95%CI, 1.54%–1.58%); and dehydration in 3.49% (95% CI, 3.45%–3.52%).
The Figure presents the adjusted 180-day survival for those with 2 or more complications that define a burdensome transition. Compared with overall survival (476 [95%CI, 475–478] days), the adjusted survival was significantly lower for all of the burdensome transitions: pneumonia, 95 (95% CI, 93–97) days; UTI, 146 (95%CI, 143–148) days; dehydration or malnutrition, 111 (95%CI, 109–113) days; and septicemia, 89 (95%CI, 87–90) days.
Figure. Adjusted 180-Day Survival of 1.3 Million Nursing Home Residents With Advanced Cognitive Impairment With 2 or More Hospitalizations for Selected Complications.
This adjusted 180-day survival curve is based on a competing risk model in nursing home residents with advanced cognitive impairment who experienced 2 or more hospitalizations for selected complications vs overall survival for those without complications. For nursing home residents with 2 or more of these complications, survival time was included up to the point of the second complication.
Discussion
Nursing home residents with advanced cognitive impairment who underwent multiple hospitalizations for the same infections or dehydration had poor survival. Prior research suggests that these common complications of dementia can be treated with the same efficacy in the NH.6 Future research is needed to understand whether these transitions are based on financial incentives, poor communication, or a lack of resources needed to diagnose and treat a NH resident.
We relied on administrative billing data to ascertain that NH residents were hospitalized for these complications. Despite this limitation, the observed survival suggests that the first hospitalization with these diagnoses for NH residents with advanced cognitive impairment should result in reconsideration of the goals of care and the appropriateness of continued hospitalizations.
Acknowledgments
Funding/Support: Funding for this research was provided by National Institute on Aging grant P01AG027296 and from the Commonwealth Fund.
Role of the Sponsor: The National Institute on Aging and the Commonwealth Fund had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Footnotes
Author Contributions: Dr Teno had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Teno, Gozalo, Tyler, Mor.
Acquisition of data: Teno, Mor.
Analysis and interpretation of data: Teno, Gozalo, Mitchell, Mor.
Drafting of the manuscript: Teno, Mitchell, Mor.
Critical revision of the manuscript for important intellectual content: Teno, Gozalo, Mitchell, Tyler, Mor.
Statistical analysis: Teno, Gozalo.
Obtained funding: Teno, Mor.
Administrative, technical, or material support: Teno, Tyler, Mor.
Study supervision: Teno, Mor.
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Teno reported serving on the National Hospice and Palliative Care Organization board of directors. Dr Mor reported serving on the board of the Tufts Health Plan Foundation, Home and Hospice Care of Rhode Island, Jewish Alliance of Rhode Island, PointRight Inc, NaviHealth Inc, hcr-Manorcare, and AcademyHealth; serving as a consultant to the Alliance for Nursing Home Quality, Abt Associates Inc, Econometric Inc, Research Triangle Inc, and AARP Public Policy Center; providing expert testimony for the Senate Health and Aging Committee on End of LIfe Care and for a Congressional Briefing by Kidney Care Partners; has received payment for lectures from the Alliance for Nursing Home Quality, Yale University, Rutgers University, and the Congressional Budget Office; and owning stock in PointRight Inc and NaviHealth Inc. No other disclosures were reported.
References
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