title: Hospice utilization in nursing homes: association with facility end-of-life care practices.
abstract: OBJECTIVE
  Hospice care provided to nursing home (NH) residents has been shown to improve the quality of end-of-life (EOL) care. However, hospice utilization in NHs is typically low. This study examined the relationship between facility self-reported EOL practices and residents' hospice use and length of stay.
  
  
  METHODS
  The study was based on a retrospective cohort of NH residents. Medicare hospice claims, Minimum Data Set, Online Survey, Certification, and Reporting system and the Area Resource File were linked with a survey of directors of nursing (DON) regarding institutional EOL practice patterns (EOLC Survey).
  
  
  METHODS
  In total, 4,540 long-term-care residents who died in 2007 in 290 facilities which participated in the EOLC Survey were included in this study.
  
  
  METHODS
  We measured NHs' tendency to offer hospice to residents and to initiate aggressive treatments (hospital transfers and feeding tubes) for EOL residents based on DON's responses to survey items. Residents' hospice utilization was determined using Medicare hospice claims.
  
  
  RESULTS
  The prevalence of hospice use was 18%. The average length of stay was 93 days. After controlling for individual risk factors, facilities' self-reported practice measures associated with residents' likelihood of using hospice were tendency to offer hospice (p = .048) and tendency to hospitalize (p = .002). Residents in NHs reporting higher tendency to hospitalize tended to enroll in hospice closer to death.
  
  
  CONCLUSIONS
  Residents' hospice utilization is not only associated with individual and facility characteristics but also with NHs' self-reported EOL care practices. Potential interventions to effect greater use of hospice may need to focus on facility-level care processes and practices.
authors.affiliation: *Address correspondence to Nan Tracy Zheng, Aging, Disability and Long-Term Care, RTI International-Waltham office, 1440 Main Street, Suite 310, Waltham, MA 02451-1623, USA. E-mail: ntzheng@rti.org.
authors.forename: Nan Tracy
authors.initials: NT
authors.lastname: Zheng
authors.forename: Dana B
authors.initials: DB
authors.lastname: Mukamel
authors.forename: Thomas V
authors.initials: TV
authors.lastname: Caprio
authors.forename: Helena
authors.initials: H
authors.lastname: Temkin-Greener
mesh_terms: D016223:Advance Directives; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D004750:Enteral Nutrition / Q000706:statistics & numerical data; D005260:Female; D017051:Hospice Care / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay; D008297:Male; D009735:Nursing Homes / Q000592:standards / Q000706:statistics & numerical data*; D011787:Quality of Health Care; D012017:Referral and Consultation / Q000592:standards / Q000706:statistics & numerical data; D012189:Retrospective Studies; D013727:Terminal Care / Q000592:standards / Q000706:statistics & numerical data*