title: End-of-Life Care Transition Patterns of Medicare Beneficiaries.
abstract: OBJECTIVE
  To characterize the patterns of transitions in care and factors associated with multiple transitions in the last 6 months of life of U.S. decedents (N = 660,132).
  
  
  METHODS
  Retrospective study.
  
  
  METHODS
  United States.
  
  
  METHODS
  Medicare beneficiaries aged 66 and older who died from July to December 2011.
  
  
  METHODS
  Transitions between healthcare settings (e.g., hospital, skilled nursing facility, inpatient hospice, home hospice, home without hospice) in the last 6 months of life. A count variable for number of transitions was summarized, and Sankey diagrams were produced to illustrate the sequences of healthcare transitions. Multivariable analyses were used to identify factors associated with likelihood of having four or more transitions.
  
  
  RESULTS
  More than 80% decedents (n = 556,437) had at least one transition within the last 6 months of life; 218,731 had four or more transitions within the last 6 months of life. The most-frequent transition pattern (19.3% of all decedents; n = 127,435) was home to hospital, back to home or skilled nursing facility, to hospital again, and then to settings other than hospital, ending with four or more transitions. The average number of transitions in the last 6 months of life varied substantially across states, ranging from 1.8 in Alaska to 3.1 in New Jersey. Transitions became more intensive for decedents approaching death. In multivariable analyses, women, blacks, individuals younger than 85, and individuals without dementia were more likely to have four or more transitions (all P < .05).
  
  
  CONCLUSIONS
  Approximately one-third of the Medicare beneficiaries who died in 2011 had four or more transitions within their last 6 months of life. Identifying interventions that can facilitate care transitions consistent with beneficiaries' preferences is warranted.
authors.affiliation: Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, Connecticut.|Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale Cancer Center and School of Medicine, Yale University, New Haven, Connecticut.
authors.forename: Shi-Yi
authors.initials: SY
authors.lastname: Wang
authors.affiliation: Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York.|James J. Peters Veterans Affairs Medical Center, Bronx, New York.
authors.forename: Melissa D
authors.initials: MD
authors.lastname: Aldridge
authors.affiliation: Cancer Outcomes, Public Policy, and Effectiveness Research Center, Yale Cancer Center and School of Medicine, Yale University, New Haven, Connecticut.|Section of General Internal Medicine, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut.
authors.forename: Cary P
authors.initials: CP
authors.lastname: Gross
authors.affiliation: Department of Health Policy and Management, School of Public Health, Yale University, New Haven, Connecticut.
authors.forename: Maureen
authors.initials: M
authors.lastname: Canavan
authors.affiliation: Department of Health Policy and Management, School of Public Health, Yale University, New Haven, Connecticut.
authors.forename: Emily
authors.initials: E
authors.lastname: Cherlin
authors.affiliation: Department of Health Policy and Management, School of Public Health, Yale University, New Haven, Connecticut.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Bradley
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003266:Continuity of Patient Care; D005260:Female; D005102:Health Expenditures; D017051:Hospice Care / Q000706:statistics & numerical data*; D006760:Hospitalization; D006801:Humans; D008297:Male; D006278:Medicare; D009735:Nursing Homes / Q000706:statistics & numerical data; D010360:Patient Transfer; D012189:Retrospective Studies; D014481:United States
keywords: Sankey diagram; end-of-life care; transitions in care