title: Variation in the place of death among nursing home residents in France.
abstract: OBJECTIVE
  recent studies have reported that hospitals have become a common place of death for nursing home residents. This study aimed to (i) measure variations in the proportion of in-hospital deaths across regions after adjustment for facility-level characteristics and (ii) identify environmental risk factors that might explain these variations in France.
  
  
  METHODS
  a cross-sectional retrospective survey was conducted in 2013.
  
  
  METHODS
  coordinating physicians in 3,705 nursing homes in France.
  
  
  METHODS
  a regression model was used to construct risk-adjusted rates of in-hospital deaths considering the facilities' characteristics. At the regional level, the outcome was defined as the difference between the observed rate of in-hospital deaths and the expected risk-adjusted rate. Values exceeding zero indicated rates that exceeded the national predicted rate of in-hospital deaths and thus highlighted regions in which the risk-adjusted probability for nursing home residents to die in a hospital was greater than average.
  
  
  RESULTS
  among 70,119 nursing home decedents, 25.4% (n = 17,789) died in hospitals. The characteristics of the facilities had a significant influence on the proportion of in-hospital deaths among the nursing home decedents. However, after adjustment for these facility-level risk factors, the proportion of nursing homes that reported worse-than-average outcomes showed significant variation (range 26.0-79.6%). At the regional level, both the rate of acute hospital beds and the rate of general practitioners were found to be strongly correlated with the probability of reporting worse-than-average outcomes (P < 0.001).
  
  
  CONCLUSIONS
  our study demonstrates the existence of major differences across regions in France and highlights the need for targeted interventions regarding end-of-life care in nursing home facilities.
authors.affiliation: French National Observatory on End-of-Life Care, Paris, France Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden.
authors.forename: Lucas
authors.initials: L
authors.lastname: Morin
authors.affiliation: Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden.
authors.forename: Kristina
authors.initials: K
authors.lastname: Johnell
authors.affiliation: University Hospital of Besancon, Besançon, France.
authors.forename: Régis
authors.initials: R
authors.lastname: Aubry
mesh_terms: D000368:Aged; D003430:Cross-Sectional Studies; D003643:Death; D005602:France / Q000453:epidemiology*; D017052:Hospital Mortality; D006801:Humans; D007326:Institutionalization / Q000706:statistics & numerical data; D015233:Models, Statistical; D009735:Nursing Homes / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012307:Risk Factors; D013727:Terminal Care / Q000706:statistics & numerical data
keywords: end-of-life care; long-term care; nursing homes; older people; place of death