title: Hospice use among nursing home patients.
abstract: OBJECTIVE
  Among hospice patients who lived in nursing homes, we sought to: (1) report trends in hospice use over time, (2) describe factors associated with very long hospice stays (>6 months), and (3) describe hospice utilization patterns.
  
  
  METHODS
  We conducted a retrospective study from an urban, Midwest cohort of hospice patients, aged ≥ 65 years, who lived in nursing homes between 1999 and 2008.
  
  
  METHODS
  Demographic data, clinical characteristics, and health care utilization were collected from Medicare claims, Medicaid claims, and Minimum Data Set assessments. Patients with overlapping nursing home and hospice stays were identified. χ(2) and t tests were used to compare patients with less than or longer than a 6-month hospice stay. Logistic regression was used to model the likelihood of being on hospice longer than 6 months.
  
  
  RESULTS
  A total of 1452 patients received hospice services while living in nursing homes. The proportion of patients with noncancer primary hospice diagnoses increased over time; the mean length of hospice stay (114 days) remained high throughout the 10-year period. More than 90% of all patients had 3 or more comorbid diagnoses. Nearly 20% of patients had hospice stays longer than 6 months. The hospice patients with stays longer than 6 months were observed to have a smaller percentage of cancer (25% vs 30%) as a primary hospice diagnosis. The two groups did not differ by mean cognitive status scores, number of comorbidities, or activities of daily living impairments. The greater than 6 months group was much more likely to disenroll before death: 33.9% compared with 13.8% (P < .0001). A variety of patterns of utilization of hospice across settings were observed; 21% of patients spent some of their hospice stay in the community.
  
  
  CONCLUSIONS
  Any policy proposals that impact the hospice benefit in nursing homes should take into account the difficulty in predicting the clinical course of these patients, varying utilization patterns and transitions across settings, and the importance of supporting multiple approaches for delivery of palliative care in this setting.
authors.affiliation: Indiana University Center for Aging Research, Indianapolis, IN 46202, USA. kunroe@iupui.edu
authors.forename: Kathleen Tschantz
authors.initials: KT
authors.lastname: Unroe
authors.forename: Greg A
authors.initials: GA
authors.lastname: Sachs
authors.forename: Susan E
authors.initials: SE
authors.lastname: Hickman
authors.forename: Timothy E
authors.initials: TE
authors.lastname: Stump
authors.forename: Wanzhu
authors.initials: W
authors.lastname: Tu
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Callahan
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D005260:Female; D006304:Health Status; D018574:Home Care Agencies / Q000706:statistics & numerical data*; D017051:Hospice Care / Q000706:statistics & numerical data*; D006738:Hospices / Q000706:statistics & numerical data*; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data*; D033183:Interdisciplinary Communication; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D009735:Nursing Homes / Q000706:statistics & numerical data*; D010166:Palliative Care / Q000706:statistics & numerical data; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology