title: Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009.
abstract: OBJECTIVE
  A recent Centers for Disease Control and Prevention report found that more persons die at home. This has been cited as evidence that persons dying in the United States are using more supportive care.
  
  
  OBJECTIVE
  To describe changes in site of death, place of care, and health care transitions between 2000, 2005, and 2009.
  
  
  METHODS
  Retrospective cohort study of a random 20% sample of fee-for-service Medicare beneficiaries, aged 66 years and older, who died in 2000 (n = 270,202), 2005 (n = 291,819), or 2009 (n = 286,282). A multivariable regression model examined outcomes in 2000 and 2009 after adjustment for sociodemographic characteristics. Based on billing data, patients were classified as having a medical diagnosis of cancer, chronic obstructive pulmonary disease, or dementia in the last 180 days of life.
  
  
  METHODS
  Site of death, place of care, rates of health care transitions, and potentially burdensome transitions (eg, health care transitions in the last 3 days of life).
  
  
  RESULTS
  Our random 20% sample included 848,303 fee-for-service Medicare decedents (mean age, 82.3 years; 57.9% female, 88.1% white). Comparing 2000, 2005, and 2009, the proportion of deaths in acute care hospitals decreased from 32.6% (95% CI, 32.4%-32.8%) to 26.9% (95% CI, 26.7%-27.1%) to 24.6% (95% CI, 24.5%-24.8%), respectively. However, intensive care unit (ICU) use in the last month of life increased from 24.3% (95% CI, 24.1%-24.5%) to 26.3% (95% CI, 26.1%-26.5%) to 29.2% (95% CI, 29.0%-29.3%). (Test of trend P value was <.001 for each variable.) Hospice use at the time of death increased from 21.6% (95% CI, 21.4%-21.7%) to 32.3% (95% CI, 32.1%-32.5%) to 42.2% (95% CI, 42.0%-42.4%), with 28.4% (95% CI, 27.9%-28.5%) using a hospice for 3 days or less in 2009. Of these late hospice referrals, 40.3% (95% CI, 39.7%-40.8%) were preceded by hospitalization with an ICU stay. The mean number of health care transitions in the last 90 days of life increased from 2.1 (interquartile range [IQR], 0-3.0) to 2.8 (IQR, 1.0-4.0) to 3.1 per decedent (IQR, 1.0-5.0). The percentage of patients experiencing transitions in the last 3 days of life increased from 10.3% (95% CI, 10.1%-10.4%) to 12.4% (95% CI, 12.3%-2.5%) to 14.2% (95% CI, 14.0%-14.3%).
  
  
  CONCLUSIONS
  Among Medicare beneficiaries who died in 2009 and 2005 compared with 2000, a lower proportion died in an acute care hospital, although both ICU use and the rate of health care transitions increased in the last month of life.
authors: Warren Alpert Medical School of Brown University, 121 S Main St, Providence, RI 02912, USA. joan_teno@brown.edu
authors: Joan M
authors: JM
authors: Teno
authors: Pedro L
authors: PL
authors: Gozalo
authors: Julie P W
authors: JP
authors: Bynum
authors: Natalie E
authors: NE
authors: Leland
authors: Susan C
authors: SC
authors: Miller
authors: Nancy E
authors: NE
authors: Morden
authors: Thomas
authors: T
authors: Scupp
authors: David C
authors: DC
authors: Goodman
authors: Vincent
authors: V
authors: Mor
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003266:Continuity of Patient Care; D003644:Death Certificates; D005260:Female; D006699:Home Care Services / Q000706:statistics & numerical data* / Q000639:trends; D017051:Hospice Care / Q000706:statistics & numerical data* / Q000639:trends; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data / Q000639:trends; D008297:Male; D006278:Medicare; D010166:Palliative Care / Q000706:statistics & numerical data / Q000639:trends; D010360:Patient Transfer; D012044:Regression Analysis; D012189:Retrospective Studies; D013727:Terminal Care / Q000706:statistics & numerical data* / Q000639:trends; D014481:United States
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