title: Dying in U.S. nursing homes with advanced dementia: how does health care use differ for residents with, versus without, end-of-life Medicare skilled nursing facility care?
abstract: BACKGROUND
  Because Medicare policy restricts simultaneous Medicare hospice and skilled nursing facility (SNF) care, we compared hospice use and sites of death for SNF/non-SNF residents with advanced dementia; and, for those with SNF, we evaluated how subsequent hospice use was associated with dying in a hospital.
  
  
  METHODS
  This study includes (non-health maintenance organization [HMO]) residents of U.S. nursing homes (NHs) who died in 2006 with advanced dementia (n=99,370). Sites of death, Medicare SNF, and hospice use were identified using linked resident assessment and Medicare enrollment and claims data. Advanced dementia was identified by a diagnosis of Alzheimer's disease or dementia on the Minimum Data Set (MDS) or a Medicare claim in the last year of life and severe to very severe cognitive impairment (5 or 6 on the MDS cognitive performance scale). For residents with SNF, we used multivariate logistic regression with generalized estimating equations to estimate the effect of subsequent hospice enrollment on dying in a hospital.
  
  
  RESULTS
  Forty percent of U.S. NH residents dying with advanced dementia in 2006 had SNF care in the last 90 days of life. Those with versus without SNF less frequently used hospice (30% versus 46%), more frequently had short (≤7 days) hospice stays (40% versus 19%), and more frequently died in hospitals (14% versus 9%). Among residents with SNF, those with subsequent hospice use had a 98% lower likelihood of a hospital death (95% confidence interval [CI]: 0.014, 0.025).
  
  
  CONCLUSIONS
  Dual hospice/SNF access may result in fewer hospital deaths and higher quality of life for dying NH residents.
authors.affiliation: Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island 02912, USA. Susan_Miller@brown.edu
authors.forename: Susan C
authors.initials: SC
authors.lastname: Miller
authors.forename: Julie C
authors.initials: JC
authors.lastname: Lima
authors.forename: Jessica
authors.initials: J
authors.lastname: Looze
authors.forename: Susan L
authors.initials: SL
authors.lastname: Mitchell
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003704:Dementia / Q000401:mortality* / Q000503:physiopathology; D005260:Female; D006738:Hospices / Q000706:statistics & numerical data*; D006801:Humans; D016015:Logistic Models; D008297:Male; D006278:Medicare; D012720:Severity of Illness Index; D012866:Skilled Nursing Facilities; D013727:Terminal Care; D014481:United States / Q000453:epidemiology