title: End-of-life transitions among nursing home residents with cognitive issues.
abstract: 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.
authors: Brown University Program in Public Health, Department of Health Services, Policy, and Practice, Brown University, Providence, RI, USA.
authors: Pedro
authors: P
authors: Gozalo
authors: Joan M
authors: JM
authors: Teno
authors: Susan L
authors: SL
authors: Mitchell
authors: Jon
authors: J
authors: Skinner
authors: Julie
authors: J
authors: Bynum
authors: Denise
authors: D
authors: Tyler
authors: Vincent
authors: V
authors: Mor
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003072:Cognition Disorders / Q000628:therapy*; D003266:Continuity of Patient Care; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D006278:Medicare; D009735:Nursing Homes; D010360:Patient Transfer / Q000706:statistics & numerical data*; D011787:Quality of Health Care; D013727:Terminal Care / Q000592:standards / Q000706:statistics & numerical data*; D014481:United States