title: Utilization of medical services at the end of life in older adults with cognitive impairment: focus on outliers.
abstract: BACKGROUND
  The use of intensive medical care near end of life is often questioned because of potential burden to patients, their families, and society. Efforts to moderate intensive end-of-life care may be facilitated by early identification of those at greatest risk for receiving such care.
  
  
  OBJECTIVE
  To examine factors associated with intensive end-of-life medical care utilization in nursing home residents with severe cognitive impairment.
  
  
  METHODS
  Retrospective review of existing Medicare data: 1998-2001 Minimum Data Set (MDS), Medicare Denominator, MedPAR, and hospice files.
  
  
  METHODS
  Subjects were Minnesota and Texas nursing home residents from rural and urban counties (USDA metro-nonmetro continuum codes: 0-2 urban, 6-9 rural), who had severe cognitive impairment and who died during 2000-2001. Hospice and managed care enrollees were excluded. High medical care users were defined as subjects with 7+ intensive care unit (ICU) days in the last 90 days of life. Measures of end-of-life medical care utilization intensity included tube feeding on the last MDS report, number of hospital and ICU days, and total hospital charges during the study period.
  
  
  RESULTS
  The study population included 1494 nursing home residents who were hospitalized within 90 days prior to death; 82 (5%) met the high medical care user criteria. In multivariable analysis: urban location (p < 0.001), lack of do-not-resuscitate directive (p = 0.002), non-white race (p = 0.021), and having 3+ comorbidities (p = 0.021) were independently associated with high medical care utilization.
  
  
  CONCLUSIONS
  Urban nursing home location and lack of do-not-resuscitate directives were the strongest predictors of high medical care utilization near the end of life.
authors.affiliation: Division of Education and Research, SMDC Health System, Duluth, Minnesota 55805-1983, USA.
authors.forename: Irina V
authors.initials: IV
authors.lastname: Haller
authors.forename: Charles E
authors.initials: CE
authors.lastname: Gessert
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003072:Cognition Disorders / Q000453:epidemiology / Q000503:physiopathology*; D015897:Comorbidity; D003657:Decision Making; D004750:Enteral Nutrition / Q000706:statistics & numerical data; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006761:Hospitals / Q000145:classification / Q000706:statistics & numerical data; D006801:Humans; D007362:Intensive Care Units / Q000191:economics / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D008484:Medicaid; D006278:Medicare; D008910:Minnesota / Q000453:epidemiology; D009735:Nursing Homes / Q000458:organization & administration*; D010166:Palliative Care / Q000706:statistics & numerical data; D011787:Quality of Health Care; D016414:Resuscitation Orders; D013727:Terminal Care / Q000191:economics / Q000379:methods* / Q000706:statistics & numerical data; D013781:Texas / Q000453:epidemiology