Racial/Ethnic Disparities in Nursing Home End-of-Life Care: A Systematic Review

Advance Directives Change Frequently in Nursing Home Residents

OBJECTIVES

To describe the rate, timing, and pattern of changes in advance directives (ADs) of do not resuscitate (DNR) and do not hospitalize (DNH) orders among new admissions to nursing homes (NHs).

DESIGN

A retrospective cohort study.

SETTING AND PARTICIPANTS

Admissions to all publicly funded NHs in Ontario, Canada, between January 1, 2013, and December 31, 2017.

METHODS

Residents were followed until discharged from incident NH stay, death, or were still present at the end of study (December 31, 2019). They were categorized into 3 mutually exclusive baseline composite AD groups: Full Code, DNR Only, and DNR+DNH. We used Poisson regression models to estimate the incidence rate ratios of AD change between different AD groups and different decision makers for personal care, adjusted for baseline clinical and sociodemographic variables.

RESULTS

A total of 102,541 NH residents were eligible for inclusion. Residents with at least 1 AD change accounted for 46% of Full Code, 30% of DNR Only, and 25% of DNR+DNH group. Median time to first AD change ranged between 26 and 55 weeks. For Full Code and DNR Only residents, the most frequent change was to an AD 1 level lower in aggressiveness or intervention, whereas for DNR+DNH residents the most frequent change was to DNR Only. About 16% of residents had 2 or more AD changes during their stay. After controlling for covariates, residents with a DNR-only order or DNR+DNH orders at admission and those with a surrogate decision maker were associated with lower AD change rates.

CONCLUSIONS AND IMPLICATIONS

Measuring AD adherence rates that are documented only at a particular time often underestimates the dynamics of AD changes during a resident's stay and results in an inaccurate measure of the effectiveness of AD on resident care. There should be more frequent reviews of ADs as they are quite dynamic. Mandatory review after an acute change in a resident's health would ensure that ADs are current.

Naming racism as a root cause of inequities in palliative care research: a scoping review

BACKGROUND

Racial and ethnic inequities in palliative care are well-established. The way researchers design and interpret studies investigating race- and ethnicity-based disparities has future implications on the interventions aimed to reduce these inequities. If racism is not discussed when contextualizing findings, it is less likely to be addressed and inequities will persist.

OBJECTIVE

To summarize the characteristics of 12 years of academic literature that investigates race- or ethnicity-based disparities in palliative care access, outcomes and experiences, and determine the extent to which racism is discussed when interpreting findings.

METHODS

Following Arksey & O'Malley's methodology for scoping reviews, we searched bibliographic databases for primary, peer reviewed studies globally, in all languages, that collected race or ethnicity variables in a palliative care context (January 1, 2011 to October 17, 2023). We recorded study characteristics and categorized citations based on their research focus-whether race or ethnicity were examined as a major focus (analyzed as a primary independent variable or population of interest) or minor focus (analyzed as a secondary variable) of the research purpose, and the interpretation of findings-whether authors directly or indirectly discussed racism when contextualizing the study results.

RESULTS

We identified 3000 citations and included 181 in our review. Of these, most were from the United States (88.95%) and examined race or ethnicity as a major focus (71.27%). When interpreting findings, authors directly named racism in 7.18% of publications. They were more likely to use words closely associated with racism (20.44%) or describe systemic or individual factors (41.44%). Racism was directly named in 33.33% of articles published since 2021 versus 3.92% in the 10 years prior, suggesting it is becoming more common.

CONCLUSION

While the focus on race and ethnicity in palliative care research is increasing, there is room for improvement when acknowledging systemic factors - including racism - during data analysis. Researchers must be purposeful when investigating race and ethnicity, and identify how racism shapes palliative care access, outcomes and experiences of racially and ethnically minoritized patients.

Race and Ethnicity Are Related to Undesirable Home Health Care Outcomes in Seriously Ill Older Adults

OBJECTIVES

Medicare Home Health Care (HHC) services are integral to the care of homebound seriously ill older adults requiring ongoing specialized medical care. Although disparities in health outcomes are well documented in inpatient and primary care, disparities experienced by historically marginalized racial and ethnic groups underrepresented in HHC are understudied. This study aimed to examine the relationship between individual characteristics and differences in HHC health outcomes for seriously ill older adults.

DESIGN

Secondary data analysis, repeated measure.

SETTING AND PARTICIPANTS

Seriously ill older adults who received HHC in 2016 in the HHC Outcome and Assessment Information Set (OASIS).

METHODS

Start of care and discharge data from the 2016 HCC OASIS were used to examine the relationship between individual characteristics and differences in HHC health outcomes identified by the Centers for Medicare and Medicaid Services as key indicators of quality in HHC, including dyspnea, pain frequency, cognitive functioning, and presence of unhealed pressure ulcer stage II or higher. A generalized ordered logit model with partial proportional odds was used for the ordinal categorical outcomes and a logistic regression was used for the binary dependent variable.

RESULTS

Findings indicated that of 227,402 seriously ill individuals with an HHC episode in 2016, those from underrepresented racial and ethnic groups had between 14% and 57% higher odds of worse health outcomes compared with non-Hispanic white patients with the exception of pain frequency.

CONCLUSIONS AND IMPLICATIONS

For people living with serious illness, there are significant differences in Medicare HHC health outcomes when comparing underrepresented racial or ethnic beneficiaries with white counterparts. More research is needed to understand how health care processes such as referral patterns or time to care initiation, and structural factors such as HHC agency quality and neighborhood social deprivation are related to health differences observed in the population.

Nurse Practitioner Care, Scope of Practice, and End-of-Life Outcomes for Nursing Home Residents With Dementia

Importance

Nursing home residents with Alzheimer disease and related dementias (ADRD) often receive burdensome care at the end of life. Nurse practitioners (NPs) provide an increasing share of primary care in nursing homes, but how NP care is associated with end-of-life outcomes for this population is unknown.

Objectives

To examine the association of NP care with end-of-life outcomes for nursing home residents with ADRD and assess whether these associations differ according to state-level NP scope of practice regulations.

Design, Setting, and Participants

This cohort study using fee-for-service Medicare claims included 334 618 US nursing home residents with ADRD who died between January 1, 2016, and December 31, 2018. Data were analyzed from April 6, 2015, to December 31, 2018.

Exposures

Share of nursing home primary care visits by NPs, classified as minimal (<10% of visits), moderate (10%-50% of visits), and extensive (>50% of visits). State NP scope of practice regulations were classified as full vs restrictive in 2 domains: practice authority (authorization to practice and prescribe independently) and do-not-resuscitate (DNR) authority (authorization to sign DNR orders).

Main Outcomes and Measures

Hospitalization within the last 30 days of life and death with hospice. Linear probability models with hospital referral region fixed effects controlling for resident characteristics, visit volume, and geographic factors were used to estimate whether the associations between NP care and outcomes varied across states with different scope of practice regulations.

Results

Among 334 618 nursing home decedents (mean [SD] age at death, 86.6 [8.2] years; 69.3% female), 40.5% received minimal NP care, 21.4% received moderate NP care, and 38.0% received extensive NP care. Adjusted hospitalization rates were lower for residents with extensive NP care (31.6% [95% CI, 31.4%-31.9%]) vs minimal NP care (32.3% [95% CI, 32.1%-32.6%]), whereas adjusted hospice rates were higher for residents with extensive (55.6% [95% CI, 55.3%-55.9%]) vs minimal (53.6% [95% CI, 53.3%-53.8%]) NP care. However, there was significant variation by state scope of practice. For example, in full practice authority states, adjusted hospice rates were 2.88 percentage points higher (95% CI, 1.99-3.77; P < .001) for residents with extensive vs minimal NP care, but the difference between these same groups was 1.77 percentage points (95% CI, 1.32-2.23; P < .001) in restricted practice states. Hospitalization rates were 1.76 percentage points lower (95% CI, -2.52 to -1.00; P < .001) for decedents with extensive vs minimal NP care in full practice authority states, but the difference between these same groups in restricted practice states was only 0.43 percentage points (95% CI, -0.84 to -0.01; P < .04). Similar patterns were observed in analyses focused on DNR authority.

Conclusions and Relevance

The findings of this cohort study suggest that NPs appear to be important care providers during the end-of-life period for many nursing home residents with ADRD and that regulations governing NP scope of practice may have implications for end-of-life hospitalizations and hospice use in this population.

Potentially Avoidable Hospitalizations Among Historically Marginalized Nursing Home Residents

Importance

Nursing home (NH) transfers to hospitals are common and have been associated with cognitive decline; approximately 45% of NH hospital transfers are potentially avoidable hospitalizations (PAHs).

Objective

To determine PAH incidence for historically marginalized NH residents with severe cognitive impairment compared with non-Hispanic White residents.

Design, Setting, and Participants

This cross-sectional study merged 2018 Centers for Medicaid & Medicare Services datasets and LTCFocus, a public dataset on US NH care, for US NH residents aged 65 years and older who had a hospitalization. Analyses were performed from January to May 2022.

Exposure

Race and ethnicity of NH residents.

Main Outcomes and Measures

Racial and ethnic differences in resident-level annual rates of PAHs were estimated for residents with and without severe cognitive impairment (measured using the Cognitive Function Scale), controlling for resident characteristics, comorbidities, dual eligibility, and time at risk. PAHs were defined as NH hospital transfers that resulted from neglectful NH care or for which NH treatment would have been appropriate.

Results

Of 2 098 385 NH residents nationwide included in the study, 7151 (0.3%) were American Indian or Alaska Native, 39 873 (1.9%) were Asian, 229 112 (10.9%) were Black or African American, 99 304 (4.7%) were Hispanic, 2785 (0.1%) were Native Hawaiian or Pacific Islander, 1 713 670 (81.7%) were White, and 6490 (0.3%) were multiracial; 1 355 143 (64.6%) were female; 128 997 (6.2%) were severely cognitively impaired; and the mean (SD) age was 81.8 (8.7) years. PAH incidence rate ratios (IRRs) were significantly greater for residents with severe cognitive impairment compared with those without. In unadjusted analyses comparing historically marginalized residents with severe cognitive impairment vs non-Hispanic White residents with severe cognitive impairment, American Indian or Alaska Native residents had a 49% higher PAH incidence (IRR, 1.49 [95% CI, 1.10-2.01]), Black or African American residents had a 64% higher incidence (IRR, 1.64 [95% CI, 1.48-1.81]), and Hispanic residents had a 45% higher incidence (IRR, 1.45 [95% CI, 1.29-1.62]). Higher incidences persisted for historically marginalized residents with severe cognitive impairment vs non-Hispanic White residents with severe cognitive impairment in adjusted analyses. Asian residents had a 24% higher PAH incidence (IRR, 1.24 [95% CI, 1.06-1.45]), Black or African American residents had a 48% higher incidence (IRR, 1.48 [95% CI, 1.36-1.60]), and Hispanic residents had a 27% higher incidence (IRR, 1.27 [95% CI, 1.16-1.39]).

Conclusions and Relevance

In this cross-sectional study of PAHs, compared with non-Hispanic White NH residents, historically marginalized residents had increased PAH incidence. In the presence of severe cognitive impairment, incidence rates increased significantly compared with rates for residents without severe cognitive impairment. These results suggest that identification of residents with severe cognitive impairment and proper NH care may help prevent further cognitive decline by avoiding PAHs.

Building evidence to advance health equity: a systematic review on care-related outcomes for older, minoritised populations in long-term care homes

BACKGROUND

Advancing health equity requires more contextualised evidence.

OBJECTIVES

To synthesise published evidence using an existing framework on the origins of health disparities and determine care-related outcome disparities for residents of long-term care, comparing minoritised populations to the context-specific dominant population.

DESIGN

Systematic review.

SUBJECTS

Residents of 24-hour long-term care homes.

METHODS

The protocol was registered a priori with PROSPERO (CRD42021269489). Literature published between 1 January 2000 and 26 September 2021, was searched, including studies comparing baseline characteristics and outcomes in minoritised versus dominant populations. Dual screening, two-reviewer verification for extraction, and risk of bias assessments were conducted to ensure rigour. Studies were synthesized using a conceptual framework to contextualise evidence according to multi-level factors contributing to the development of care disparities.

RESULTS

Twenty-one of 34 included studies demonstrated disparities in care outcomes for minoritised groups compared to majority groups. Thirty-one studies observed differences in individual-level characteristics (e.g. age, education, underlying conditions) upon entry to homes, with several outcome disparities (e.g. restraint use, number of medications) present at baseline and remaining or worsening over time. Significant gaps in evidence were identified, particularly an absence of literature on provider information and evidence on the experience of intersecting minority identities that contribute to care-related outcome disparities in long-term care.

CONCLUSION

This review found differences in minoritised populations' care-related outcomes. The findings provide guidance for future health equity policy and research-supporting diverse and intersectional capacity building in long-term care.

American Muslim Engagement With Advance Care Planning: Insights From a Community Survey

Background and Objectives: Advance Care Planning (ACP) is a critical tool in advancing patient self-determination in health care delivery. Despite increasing research into racial/ethnic minorities' engagement with ACP in the US, studies on Muslim Americans are relatively scarce. We aimed to examine levels of ACP engagement among Muslim adults and measure associations between socio-demographic and religiosity characteristics and ACP engagement. Methodology: This was a survey study among Muslims attending mosque seminars in Chicago and Washington DC. Religiosity characteristics were assessed using a modified version of the Duke University Religion Index (DUREL) and the Psychological Measure of Islamic Religiousness (PMIR). ACP engagement was measured by the 4-item ACP Engagement Survey (4-ACPES) and 2 additional items covering ACP religious dimensions. Statistical analyses were performed using SPSS 28.0. Results: Out of 152 respondents, 56.2% to 72.6% were in the pre-contemplation stage of ACP across the 6 ACP items. Bivariate analyses showed that ACP engagement was correlated with participant age, ethnicity, duration of stay in the US and country of birth. Multivariable analyses demonstrated no association between religiosity characteristics and ACP engagement; independent predictors of ACP engagement were race/ethnicity (being South Asian), country of birth (born outside the US) and duration of stay in the US (longer years). Discussion/Conclusion: Our study suggests that American Muslims are largely unprepared to engage with ACP. Moreover, religiosity does not predict ACP engagement. We call for greater community outreach and educational programs that instill awareness and knowledge on the importance of ACP, and provide resources for tailored religiously-oriented conversations that assist individuals with ACP.

Mapping racial and ethnic healthcare disparities for persons living with dementia: A scoping review

INTRODUCTION

We set out to map evidence of disparities in Alzheimer's disease and Alzheimer's disease related dementias healthcare, including issues of access, quality, and outcomes for racial/ethnic minoritized persons living with dementia (PLWD) and family caregivers.

METHODS

We conducted a scoping review of the literature published from 2000 to 2022 in PubMed, PsycINFO, and CINAHL. The inclusion criteria were: (1) focused on PLWD and/or family caregivers, (2) examined disparities or differences in healthcare, (3) were conducted in the United States, (4) compared two or more racial/ethnic groups, and (5) reported quantitative or qualitative findings.

RESULTS

Key findings include accumulating evidence that minoritized populations are less likely to receive an accurate and timely diagnosis, be prescribed anti-dementia medications, and use hospice care, and more likely to have a higher risk of hospitalization and receive more aggressive life-sustaining treatment at the end-of-life.

DISCUSSION

Future studies need to examine underlying processes and develop interventions to reduce disparities while also being more broadly inclusive of diverse populations.

A Nurse Practitioner-Driven Palliative and Supportive Care Service in Nursing Homes: Evaluation of a Quality Improvement Project

This article describes a quality improvement project implemented by a national postacute long-term care organization aimed at enhancing the provision of palliative care to nursing home residents. The project focused on improving advance care planning, end-of-life care, symptom management, and care of people living with serious illness. Both generalist and specialist palliative care training were provided to nurse practitioners in addition to implementing a system to identify residents most likely to benefit from a palliative approach to care. To evaluate the nurse practitioner experiences of the program, survey data were collected from nurse practitioners (N = 7) involved in the project at 5 months after implementation. Nurse practitioners reported the program was well received by nursing home staff, families, and residents. Most nurse practitioners felt more confident managing residents' symptoms and complex care needs; however, some reported needing additional resources for palliative care delivery. Most common symptoms that were managed included pain, delirium, and dyspnea; most common diagnoses cared for were dementia and chronic organ failure (eg, cardiac, lung, renal, and neurological diseases). In the next steps, the project will be expanded throughout the organization, and person- and family-centered outcomes will be evaluated.

End-of-Life Planning and the Influence of Socioeconomic Status among Black Americans: A Systematic Review

Purpose

The purpose of this systematic review is to explore end-of-life (EOL) care planning and the impact of socioeconomic status (SES) among people who identify as Black or African American.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) were used to guide and inform this systematic review process. The following academic electronic databases with publications that reflected the interdisciplinary fields related to the research objective were searched APA PsycINFO, CINHAL, PubMed, Scopus, and Social Work Abstracts.

Results

After the authors conducted the search, 14 articles (from 13 studies) ultimately met the criteria for inclusion. The results substantiated significant concerns highlighted in previous literature regarding SES and its relation to EOL planning, but also revealed an absence of original work and interventions to increase engagement in EOL planning among Black and African American populations.

Conclusion

Black individuals deserve an equitable EOL experience. Researchers, practitioners, and policymakers need to move towards advocacy and action to meet this important need.

Population-level quality indicators of end-of-life-care in an aged care setting: Rapid systematic review

BACKGROUND

As their health declines, many older adults require additional care and move to residential aged care facilities. Despite efforts to reduce it, variation persists in care quality at the end-of-life (EOL) between facilities. Indicators to monitor care variation are therefore required. This rapid systematic review aims to identify population-level indicators of the quality of end-of-life-care (EOLC) for residents of aged care.

METHOD

A rapid systematic review of five databases (MEDLINE, Embase, CINAHL, PsycINFO, Scopus) for studies that reported on the development, assessment or validation of at least one measure of EOLC quality for residents living in an aged care setting from 1 January 2000 to 18 April 2023 was conducted. Abstracts and full-texts were screened by two reviewers and each indicator critically appraised. Key characteristics of each study were extracted.

RESULTS

From seven studies, 106 EOLC quality indicators (75 of which were unique) for aged care residents were identified. Five studies specifically identified EOLC indicators for older residents with cognitive impairment. The EOLC quality indicators were diverse in nature. There were 31 EOLC quality indicators (22 unique indicators) focused on the structure and process of care provided and 51 (38 unique indicators) identified physical and psychological aspects of care. Twenty-three EOLC quality indicators (14 unique indicators) related to care of the imminently dying patient.

CONCLUSION

A common suite of population-level EOLC indicators that are reflective of care quality, are clinically appropriate, and important to residents and their families should be identified to monitor EOLC quality within and across jurisdictions.

Family Ties at End-of-Life: Characteristics of Nursing Home Decedents With and Without Family

Background

Little is known about nursing home (NH) residents' family characteristics despite the important role families play at end-of-life (EOL).

Objective

To describe the size and composition of first-degree families (FDFs) of Utah NH residents who died 1998-2016 (n = 43,405).

Methods

Using the Utah Population Caregiving Database, we linked NH decedents to their FDF (n = 124,419; spouses = 10.8%; children = 55.3%; siblings = 32.3%) and compared sociodemographic and death characteristics of those with and without FDF members (n = 9424).

Results

Compared to NH decedents with FDF (78.3%), those without (21.7%) were more likely to be female (64.7% vs. 57.1%), non-White/Hispanic (11.2% vs. 4.2%), less educated (<9th grade; 41.1% vs. 32.4%), and die in a rural/frontier NH (25.3% vs. 24.0%, all p < 0.001). Despite similar levels of disease burden (Charlson Comorbidity score 3 + 37.7% vs. 38.0%), those without FDF were more likely to die from cancer (14.2% vs. 12.4%), Chronic Obstructive Pulmonary Disease (COPD) (6.0% vs. 4.0%), and dementia (17.1% vs. 16.6%, all p < 0.001), and were less likely to have 2+ hospitalizations at EOL (20.5% vs. 22.4%, p < 0.001).

Conclusions

Among NH decedents, those with and without FDF have different sociodemographic and death characteristics-factors that may impact care at EOL. Understanding the nature of FDF relationship type on NH resident EOL care trajectories and outcomes is an important next step in clarifying the role of families of persons living and dying in NHs.

Trust as a Central Factor in Hospice Enrollment Disparities Among Ethnic and Racial Minority Patients: A Qualitative Study of Interrelated and Compounding Factors Impacting Trust

Background: Disparities in end-of-life (EOL) care remain among ethnic/racial minority populations. Choosing hospice care in the United States depends on goals-of-care discussions founded on trust. While studies examine hospice enrollment disparities and others explore trust in hospice settings in general, very few explicitly examine the role of trust in hospice enrollment disparities. Objectives: To explore factors impacting trust and how these might contribute to disparities in hospice enrollment. Design: A qualitative, individual interview study, based on grounded theory. Setting/Subjects: Setting: Rhode Island, USA. Participants: Multiple stakeholders in EOL care, with diverse professional and personal backgrounds. Measurements: In-depth semistructured individual interviews were audio-recorded and transcribed as part of a broader study of hospice enrollment barriers in diverse patients. Analysis: Five researchers did a secondary data analysis, focusing on trust as the central phenomenon of interest. Researchers independently analyzed transcripts, then held iterative group analysis meetings until they reached consensus regarding themes, subthemes, and relationships. Results: Twenty-two participants included five physicians, five nurses, three social workers, two chaplains, one nursing assistant, three administrators, and three patient caregivers/family. Interviews reveal that trust is multidimensional, involving personal- and systems-level trust, and both locus and degree of trust. Factors impacting trust include: fear; communication/relationships; knowledge of hospice; religious/spiritual beliefs; language; and cultural beliefs/experiences. While some are common across groups, several are more prevalent in minority populations. These factors appear to interact in complex ways, unique to individual patients/families, compounding their impact on trust. Conclusions: While gaining patient/family trust regarding EOL decision making is challenging across all groups, minority patients often experience additional compounding factors impacting trust building. More research is needed to mitigate the negative ways these interacting factors impact trust.

Trends and determinants of place of death among Chinese lymphoma patients: a population-based study from 2013-2021

Limited research exists on factors influencing the place of death (POD) or hospital deaths among lymphoma patients in China, despite the country's significant burden of lymphoid neoplasms. This study aimed to describe the distribution of POD among lymphoma patients and identify the factors associated with hospital lymphoma deaths to provide evidence for developing targeted healthcare policies. Data in this study were obtained from the National Mortality Surveillance System (NMSS). The distribution of POD among individuals who died from lymphoma was analyzed, and factors influencing the choice of dying in the hospital were examined. Chi-square test was employed to analyze the differences in characteristic distributions. Multilevel logistic regression analysis was identify the relationship between hospital deaths due to lymphoma and individual factors, as well as socioeconomic contextual variables. During 2013-2021, there were 66772 lymphoma deaths reported by the NMSS, including 44327 patients (66.39%) who died at home and 21211 (31.77%) died in the hospital. Female patients, those had a higher level of educational attainment, retired individuals, those died of non-Hodgkin lymphoma, residents of urban areas, patients between the ages of 0 and 14, and unmarried individuals had a higher probability of dying in hospitals. Improving health care providers' understanding of palliative care for cancer patients and prioritizing accessible services are essential to enhance the quality of end-of-life care. These approaches ensure the equitable allocation of healthcare resources and provide diverse options for minorities with specific preferences regarding end-of-life care.

Exploring the relationship between patient-relevant outcomes and Alzheimer's disease progression assessed using the clinical dementia rating scale: a systematic literature review

Background

People with Alzheimer's disease (AD) have difficulties in performing activities of daily living (ADLs) as the disease progresses, commonly experience neuropsychiatric symptoms (NPS), and often have comorbidities such as cardiovascular disease. These factors all contribute to a requirement for care and considerable healthcare costs in AD. The Clinical Dementia Rating (CDR) scale is a widely used measure of dementia staging, but the correlations between scores on this scale and patient-/care partner-relevant outcomes have not been characterized fully. We conducted a systematic literature review to address this evidence gap.

Methods

Embase, MEDLINE, and the Cochrane Library were searched September 13, 2022, to identify published studies (no restriction by date or country) in populations with mild cognitive impairment due to AD or AD dementia. Studies of interest reported data on the relationships between CDR Global or CDR-Sum of Boxes (CDR-SB) scores and outcomes including NPS, comorbidities, ADLs, nursing home placement, healthcare costs, and resource use.

Results

Overall, 58 studies met the inclusion criteria (42 focusing on comorbidities, 14 on ADLs or dependence, five on nursing home placement, and six on economic outcomes). CDR/CDR-SB scores were correlated with the frequency of multiple NPS and with total scores on the Neuropsychiatric Inventory. For cardiovascular comorbidities, no single risk factor was consistently linked to AD progression. Increasing CDR/CDR-SB scores were correlated with decline in multiple different measures of ADLs and were also associated with nursing home placement and increasing costs of care.

Conclusion

NPS, ADLs, and costs of care are clearly linked to AD progression, as measured using CDR Global or CDR-SB scores, from the earliest stages of disease. This indicates that scores derived from the CDR are a meaningful way to describe the severity and burden of AD for patients and care partners across disease stages.

Factors Influencing RNs' Intention to Stay in Nursing Homes: Multilevel Modeling Approach

The current study investigated factors that influence the intention to stay (ITS) of RNs working in South Korean nursing homes (NHs). Thirty-six questionnaire responses from organizational NHs and 101 from individual RNs were analyzed using multilevel regression analysis. At the individual level, RNs' ITS increased with years of work at their current NH, and that of RNs who received emergency calls to work at night was lower than that of RNs with fixed night shifts. At the organizational level, ITS was higher when the ratios of RNs to residents and RNs to nursing staff were higher. To improve ITS, NHs should consider adopting mandatory deployment of RNs, increasing their RN to resident ratios, and implementing a fixed night shift RN system, wherein night shift working hours count as twice the daytime hours, and night shift is voluntary. [Journal of Gerontological Nursing, 49(7), 40-48.].

Pathways of Individuals Experiencing Serious Illness While Homeless: An Exploratory 4-Point Typology from the RASCAL-UP Study

The shifting age demographics of those experiencing homelessness in the United States expose shortcomings and barriers within homelessness response services and safety-net healthcare to address serious illness. The purpose of this study is to describe the common trajectories of patients concurrently experiencing homelessness and serious illness. As a part of the Research, Action, and Supportive Care at Later-life for Unhoused People (RASCAL-UP) study, the study uses patient charts (n = 75) from the only specialty palliative care program in the U.S. specifically for people experiencing homelessness. Through a thematic mixed-method analysis, a four-point typology of care pathways taken by people experiencing homelessness while seriously ill is introduced: (1) aging and dying-in-place within the housing care system; (2) frequent transitions during serious illness; (3) healthcare institutions as housing; and (4) housing as palliation. Implications of this exploratory typology include targeted, site-specific interventions for supporting goal-concordant patient care and assisting researchers and policy makers in appreciating heterogeneity in experience and need among older and chronically ill people experiencing homelessness and housing precarity.

A comparison of conceptual frameworks to examine health inequities in End-of-Life care

AIMS

To discuss existing conceptual frameworks that can be applied to the examination of health inequities in end-of-life care and related health outcomes. We used the Fawcett and Desanto-Madeya evaluation technique modified by the National Institute on Minority Health and Health Disparities Research Framework to include individual, interpersonal, community, and societal levels of influence.

DESIGN

Discussion paper.

DATA SOURCES

We performed a systematic review of PubMed, CINAHL and Embase for conceptual frameworks of health inequities in end-of-life care and health outcomes published as of February 2022.

IMPLICATIONS FOR NURSING

There is a strong need for research that can address multiple factors influencing end-of-life care inequities and health outcomes. To mitigate the complex nature of social determinants of health and structural inequities, researchers, clinicians, educators and administrators should have solid conceptualizations of these multi-level factors. Based on sound and comprehensive frameworks, nurses with interdisciplinary partnerships can promote health equity with a broader health care scope through addressing social determinants of health.

CONCLUSION

We identified and reviewed three frameworks. We concluded all three frameworks have the potential for use in the examination of health inequities in end-of-life care and health outcomes. However, the Conceptual Framework of Minority Access to End-of-Life Care was more applicable to diverse studies and settings when adapted to include fundamental characteristics such as sex and gender.

IMPACT

Despite the substantial rise in end-of-life care delivery, health inequities persist in end-of-life care access and utilization. Though some studies have been conducted to promote health equity by addressing social determinants of health, progress is hampered by their complex and multi-faceted nature. Through a concrete conceptual framework, researchers can comprehensively examine multi-level factors influencing health inequities in end-of-life care.

NO PATIENT OR PUBLIC CONTRIBUTION

This discussion paper focused on reviewing existing evidence.

Telehealth Palliative Care in Nursing Homes: A Scoping Review

OBJECTIVES

Many adults older than 65 spend time in a nursing home (NH) at the end of life where specialist palliative care is limited. However, telehealth may improve access to palliative care services. A review of the literature was conducted to synthesize the evidence for telehealth palliative care in NHs to provide recommendations for practice, research, and policy.

DESIGN

Joanna Briggs Institute guidance for scoping reviews, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews frameworks were used to guide this literature review.

SETTINGS AND PARTICIPANTS

Reviewed articles focused on residents in NHs with telehealth palliative care interventionists operating remotely. Participants included NH residents, care partner(s), and NH staff/clinicians.

METHODS

We searched Medline (Ovid), Embase (Elsevier), Cochrane Library (WileyOnline), Scopus (Elsevier), CINHAL (EBSCOhost), Trip PRO, and Dissertations & Theses Global (ProQuest) in June 2021, with an update in January 2022. We included observational and qualitative studies, clinical trials, quality improvement projects, and case and clinical reports that self-identified as telehealth palliative care for NH residents.

RESULTS

The review yielded 11 eligible articles published in the United States and internationally from 2008 to 2020. Articles described live video as the preferred telehealth delivery modality with goals of care and physical aspects of care being most commonly addressed. Findings in the articles focused on 5 patient and family-centered outcomes: symptom management, quality of life, advance care planning, health care use, and evaluation of care. Consistent benefits of telehealth palliative care included increased documentation of goals of care and decrease in acute care use. Disadvantages included technological difficulties and increased NH financial burden.

CONCLUSIONS AND IMPLICATIONS

Although limited in scope and quality, the current evidence for telehealth palliative care interventions shows promise for improving quality and outcomes of serious illness care in NHs. Future empirical studies should focus on intervention effectiveness, implementation outcomes (eg, managing technology), stakeholders' experience, and costs.

Trends in Obesity Prevalence among US Older Adults in the Last Two Years of Life, 1998-2018

CONTEXT

The prevalence of obesity has grown in the US over the decades. The temporal trends of body mass index categories in the last two years of life are poorly understood.

OBJECTIVES

To describe the trends in body mass categories in the last two years of life over the past two decades controlling for other demographic changes.

METHODS

We performed a cross-sectional study of prospectively collected survey data from the nationally representative Health and Retirement Study (HRS) among decedents who died between 1998 and 2018. We categorized BMI into five categories and calculated the proportion of decedents with each BMI category during each four epochs (1998-2003, 2004-2008, 2009-2013, 2014-2018). We examined trends in regression models with survey wave groupings modeled as an orthogonal polynomial and adjusted for factors commonly associated with BMI: sex, age, race, ethnicity, education, and tobacco use.

RESULTS

The analytic cohort included 14,797 decedents. From 1998-2003 to 2014-2018 time periods, those categorized as having mild-to-moderate obesity in the last two years of life increased from 12.4% to 14.8% (linear trend P < 0.001), a 19% increase. Severe obesity increased from 1.9% to 4.3%, a 126% increase (linear trend P < 0.001). Underweight decreased from 9.9% to 5.9%, a 40% decrease (linear trend P < 0.001), adjusted for demographic factors. Adjusted quadratic temporal trends for BMI category were nonsignificant, except for in mild-to-moderate obesity.

CONCLUSION

Severe obesity has increased greatly while underweight has decreased. As obesity increases in the final years of life, it is critical to assess how the existing and future palliative services and end of life care system address body size and weight.

Incidence of Aggressive End-of-Life Care Among Older Adults With Metastatic Cancer Living in Nursing Homes and Community Settings

IMPORTANCE

Nearly 10% of the 1.5 million persons residing in nursing homes (NHs) have received or will receive a diagnosis of cancer. Although aggressive end-of-life (EOL) care is common among community-dwelling patients with cancer, little is known about such patterns of care among NH residents with cancer.

OBJECTIVE

To compare markers of aggressive EOL care between older adults with metastatic cancer who are NH residents and their community-dwelling counterparts.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used the Surveillance, Epidemiology, and End Results database linked with the Medicare database and the Minimum Data Set (including NH clinical assessment data) for deaths occurring from January 1, 2013, to December 31, 2017, among 146 329 older patients with metastatic breast, colorectal, lung, pancreas, or prostate cancer, with a lookback period in claims data through July 1, 2012. Statistical analysis was conducted between March 2021 and September 2022.

EXPOSURES

Nursing home status.

MAIN OUTCOMES AND MEASURES

Markers of aggressive EOL care were cancer-directed treatment, intensive care unit admission, more than 1 emergency department visit or more than 1 hospitalization in the last 30 days of life, hospice enrollment in the last 3 days of life, and in-hospital death.

RESULTS

The study population included 146 329 patients 66 years of age or older (mean [SD] age, 78.2 [7.3] years; 51.9% men). Aggressive EOL care was more common among NH residents than community-dwelling residents (63.6% vs 58.3%). Nursing home status was associated with 4% higher odds of receiving aggressive EOL care (adjusted odds ratio [aOR], 1.04 [95% CI, 1.02-1.07]), 6% higher odds of more than 1 hospital admission in the last 30 days of life (aOR, 1.06 [95% CI, 1.02-1.10]), and 61% higher odds of dying in the hospital (aOR, 1.61 [95% CI, 1.57-1.65]). Conversely, NH status was associated with lower odds of receiving cancer-directed treatment (aOR, 0.57 [95% CI, 0.55-0.58]), intensive care unit admission (aOR, 0.82 [95% CI, 0.79-0.84]), or enrollment in hospice in the last 3 days of life (aOR, 0.89 [95% CI, 0.86-0.92]).

CONCLUSIONS AND RELEVANCE

Despite increased emphasis to reduce aggressive EOL care in the past several decades, such care remains common among older persons with metastatic cancer and is slightly more prevalent among NH residents than their community-dwelling counterparts. Multilevel interventions to decrease aggressive EOL care should target the main factors associated with its prevalence, including hospital admissions in the last 30 days of life and in-hospital death.

Health inequalities for older people from minority ethnic groups receiving palliative care and end of life care: A scoping review protocol

OBJECTIVE

The proposed scoping review aims to explore international literature on how older people from minority ethnic groups engage with and utilise palliative and end of life care, investigate the barriers and facilitators, and compare how this varies between ethnicities and health conditions.

INTRODUCTION

Minority ethnic groups make up substantial parts of the populations of many countries around the world. Research has found that there are disparities in access to palliative care and end of life care among minority ethnic groups. Language barriers, cultural values, and socio-demographic factors have been cited as preventing access to quality palliative and end of life care. However, it is unclear how these barriers and inequalities differ across different minority ethnic groups in different countries, and across different health conditions within these groups.

INCLUSION CRITERIA

The population will be older people of different minority ethnic groups who are receiving palliative or end of life care, family caregivers, and health and social care professionals. The sources of information will include quantitative, qualitative and mixed methods research, and sources that focus on minority ethnic groups' interactions with palliative and end of life care.

METHODS

A scoping review guided by the Joanna Briggs Institute Manual for Evidence Synthesis. Searches of MEDLINE, Embase, PsycInfo, CINAHL, Scopus, Web of Science, Assia, and the Cochrane Library will be conducted. Citation tracking, reference list checking and grey literature searches will be undertaken. Data will be extracted, charted and summarised descriptively.

IMPLICATIONS

This review will highlight the health inequalities present in palliative and end of life care, the research gaps in understudied minority ethnic populations, locations where further study is required, and how barriers and facilitators differ across different ethnic groups and health conditions. The results of this review will be shared with stakeholders and will provide evidence-based recommendations for inclusive palliative and end of life care.

Racial and Ethnic Differences in Informal and Formal Advance Care Planning Among U.S. Older Adults

OBJECTIVE

To examine advance care planning (ACP) trends among an increasingly diverse aging population, we compared informal and formal ACP use by race/ethnicity among U.S. older adults (≤65 years).

METHODS

We used Health and Retirement Study data (2012-2018) to assess relationships between race/ethnicity and ACP type (i.e., no ACP, informal ACP only, formal ACP only, or both ACP types). We reported adjusted risk ratios with 95% confidence intervals.

RESULTS

Non-Hispanic Black and Hispanic respondents were 1.77 (1.60, 1.96) and 1.76 (1.55, 1.99) times as likely, respectively, to report no ACP compared to non-Hispanic White respondents. Non-Hispanic Black and Hispanic respondents were 0.74 (0.71, 0.78) and 0.74 (0.69, 0.80) times as likely, respectively, to report using both ACP types as non-Hispanic White respondents.

DISCUSSION

Racial/ethnic differences in ACP persist after controlling for a variety of barriers to and facilitators of ACP which may contribute to disparities in end-of-life care.

Healthcare for older adults in North America: challenges, successes and opportunities

Older adults in North America face similar challenges to successful ageing as other adults around the world, including an increased risk of geriatric syndromes and functional decline, limited access to healthcare professionals specialising in geriatrics and constraints on healthcare spending for Long-Term Services and Supports. Geriatrics as a specialty has long been established, along with the creation of a variety of screening tools for early identification of geriatric syndromes. Despite this, workforce shortages in all older adult care service areas have led to significant gaps in care, particularly in community settings. To address these gaps, innovative programs that expand the reach of geriatric specialists and services have been developed. Opportunities exist for further dissemination of these programs and services, as well as for expansion of an ageing capable workforce.

Racial Disparities in Care Interactions and Clinical Outcomes in Black Versus White Nursing Home Residents With Dementia

BACKGROUND

With the increase in Black nursing home residents, racial and ethnic disparities in quality of care have been raised.

PURPOSE

The purpose of this study was to evaluate racial disparities in care and outcomes over 12 months.

METHODS

This was a secondary data analysis using data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia study. A total of 553 residents, 24% Black residents and 76% White residents, from 55 nursing homes were included.

RESULTS

Differences favoring Black resident were noted in agitation, quality of life, inclusion of person-centered care approaches in care plans, and fewer falls and hospitalizations. Differences in quality-of-care interactions favored White residents. There were no differences in depression, resistiveness to care, function, pain, or transfers to the emergency department.

CONCLUSIONS

Disparities in clinical outcomes were small and generally favored Black versus White residents except for quality-of-care interactions.

Structural Racism, Place, and COVID-19: A Narrative Review Describing How We Prepare for an Endemic COVID-19 Future

Background:

Place is a social determinant of health, as recently evidenced by COVID-19. Previous literature surrounding health disparities in the United States often fails to acknowledge the role of structural racism on place-based health disparities for historically marginalized communities (i.e., Black and African American communities, Hispanic/Latinx communities, Indigenous communities [i.e., First Nations, Native American, Alaskan Native, and Native Hawaiian], and Pacific Islanders). This narrative review summarizes the intersection between structural racism and place as contributors to COVID-19 health disparities.

Methods:

This narrative review accounts for the unique place-based health care experiences influenced by structural racism, including health systems and services and physical environment. We searched online databases for peer-reviewed and governmental sources, published in English between 2000 and 2021, related to place-based U.S. health inequities in historically marginalized communities. We then narrate the link between the historical trajectory of structural racism and current COVID-19 health outcomes for historically marginalized communities.

Results:

Structural racism has infrequently been named as a contributor to place as a social determinant of health. This narrative review details how place is intricately intertwined with the results of structural racism, focusing on one's access to health systems and services and physical environment, including the outdoor air and drinking water. The role of place, health disparities, and structural racism has been starkly displayed during the COVID-19 pandemic, where historically marginalized communities have been subject to greater rates of COVID-19 incidence and mortality.

Conclusion:

As COVID-19 becomes endemic, it is crucial to understand how place-based inequities and structural racism contributed to the COVID-19 racial disparities in incidence and mortality. Addressing structurally racist place-based health inequities through anti-racist policy strategies is one way to move the United States toward achieving health equity.

Does ethnicity affect pain management for people with advanced disease? A mixed methods cross-national systematic review of 'very high' Human Development Index English-speaking countries

BACKGROUND

Racial disparities in pain management have been observed in the USA since the 1990s in settings such as the emergency department and oncology. However, the palliative care context is not well described, and little research has focused outside of the USA or on advanced disease. This review takes a cross-national approach to exploring pain management in advanced disease for people of different racial and ethnic groups.

METHODS

Mixed methods systematic review. The primary outcome measure was differences in receiving pain medication between people from different racial and ethnic groups. Five electronic databases were searched. Two researchers independently assessed quality using JBI checklists, weighted evidence, and extracted data. The quantitative findings on the primary outcome measure were cross-tabulated, and a thematic analysis was undertaken on the mixed methods studies. Themes were formulated into a conceptual/thematic matrix. Patient representatives from UK ethnically diverse groups were consulted. PRISMA 2020 guidelines were followed.

RESULTS

Eighteen papers were included in the primary outcome analysis. Three papers were rated 'High' weight of evidence, and 17/18 (94%) were based in the USA. Ten of the eighteen (56%) found no significant difference in the pain medication received between people of different ethnic groups. Forty-six papers were included in the mixed methods synthesis; 41/46 (89%) were based in the USA. Key themes: Patients from different ethnically diverse groups had concerns about tolerance, addiction and side effects. The evidence also showed: cultural and social doctor-patient communication issues; many patients with unmet pain management needs; differences in pain assessment by racial group, and two studies found racial and ethnic stereotyping.

CONCLUSIONS

There was not enough high quality evidence to draw a conclusion on differences in receiving pain medication for people with advanced disease from different racial and ethnic groups. The mixed methods findings showed commonalities in fears about pain medication side effects, tolerance and addiction across diverse ethnic groups. However, these fears may have different foundations and are differently prioritised according to culture, faith, educational and social factors. There is a need to develop culturally competent pain management to address doctor-patient communication issues and patients' pain management concerns.

TRIAL REGISTRATION

PROSPERO- CRD42020167890 .

Examining Regional Differences in Nursing Home Palliative Care for Black and Hispanic Residents

Background: Approximately one-quarter of all deaths in the United States occur in nursing homes (NHs). Palliative care has the potential to improve NH end-of-life care, but more information is needed on the provision of palliative care in NHs serving Black and Hispanic residents. Objective: To determine whether palliative care services in United States NHs are associated with differences in the concentrations of Black and Hispanic residents, respectively, and the impact by region. Design: We conducted a cross-sectional analysis. The outcome was NH palliative care services (measured by an earlier national survey); total scores ranged from 0 to 100 (higher scores indicated more services). Other data included the Minimum Data Set and administrative data. The independent variables were concentration of Black and Hispanic residents (i.e., <3%, 3-10%, >10%), respectively, and models were stratified by region (i.e., Northeast, Midwest, South and West). We compared unadjusted, weighted mean palliative care services by the concentration of Black and Hispanic residents and computed NH-level multivariable linear regressions. Setting/Subjects: Eight hundred sixty-nine (weighted n = 15,020) NHs across the United States. Results: Multivariable analyses showed fewer palliative care services provided in NHs with greater concentrations of Black and Hispanic residents. Fewer palliative care services were reported in NHs in the Northeast, for which >10% of the resident population was Black, and NHs in the West for which >10% was Hispanic versus NHs with <3% of the population being Black and Hispanic (-13.7; p < 0.001 and -9.3; p < 0.05, respectively). Conclusion: We observed differences in NH palliative care by region and with greater concentration of Black and Hispanic residents. Our findings suggest that greater investment in NH palliative care services may be an important strategy to advance health equity in end-of-life care for Black and Hispanic residents.

Experience of African American Surrogate Decision Makers of Patients With Dementia

Dementia cases are expected to grow for African Americans and surrogate decision makers (SDMs) will have a significant role at the end of life (EOL). This qualitative exploratory case study used Cognitive Task Analysis and an integrated conceptual framework to understand the EOL decision experience of African American SDMs for patients with advanced dementia. Using a holistic multiple-case design, 8 African American SDMs were interviewed about their experiences with the decision-making process, including role acceptance, role enactment, and emotional outcomes of decision making. Thirteen themes germane to understanding the EOL decision experience of African American SDMs were identified. Findings suggest African American SDMs often lack sufficient knowledge of disease prognosis and intervention options to make informed treatment choices at EOL. In particular, African Americans extend the caregiver role to SDM for patients with dementia at EOL without being fully aware of the role and decision-making responsibilities. Surrogates lacked a general understanding of EOL options resulting in underutilization of hospice and palliative care and subsequent regret, and few interventions exist to improve the uptake of EOL care services. There is a need to develop culturally appropriate role preparation, education, and decision support to improve EOL treatment decisions and emotional adjustment of surrogates of patients with advanced dementia, which should be rendered early and throughout the illness trajectory.

COVID-19 Across the Landscape of Long-Term Care in Alameda County: Heterogeneity and Disparities

Throughout the pandemic, public health and long-term care professionals in our urban California county have linked local and state COVID-19 data and performed observational exploratory analyses of the impacts among our diverse long-term care facilities (LTCFs). Case counts from LTCFs through March 2021 included 4309 (65%) in skilled nursing facilities (SNFs), 1667 (25%) in residential care facilities for the elderly (RCFEs), and 273 (4%) in continuing care retirement communities (CCRCs). These cases led to 582 COVID-19 resident deaths and 12 staff deaths based on death certificates. Data on decedents' age, race, education, and country of birth reflected a hierarchy of wealth and socioeconomic status from CCRCs to RCFEs to SNFs. Mortality rates within SNFs were higher for non-Whites than Whites. Staff accounted for 42% of LTCF-associated COVID-19 cases, and over 75% of these staff were unlicensed. For all COVID-19 deaths in our jurisdiction, both LTCF and community, 82% of decedents were age 65 or over. Taking a comprehensive, population-based approach across our heterogenous LTCF landscape, we found socioeconomic disparities within COVID-19 cases and deaths of residents and staff. An improved data infrastructure linking public health and delivery systems would advance our understanding and potentiate life-saving interventions within this vulnerable ecosystem.

Reliability and Validity of the Cornell Scale for Depression in Dementia and Invariance Between Black Versus White Residents in Nursing Homes

OBJECTIVES

The purpose of this study was to expand on prior work testing invariance on several depression measures in community-based older adults and explore the psychometric properties and evidence of invariance between racial groups based on the Cornell Scale for Depression in Dementia.

DESIGN

This was a descriptive measurement study.

SETTING AND PARTICIPANTS

This was a secondary data analysis using baseline data from 2 studies: Testing the Implementation of the Evidence Integration Triangle for Behavioral and Psychological Symptoms Associated with Dementia and the study Testing the Impact of Function and Behavior Focused Care for Nursing Home Residents with Dementia. Combined, 67 nursing homes participated from 2 states and 889 residents were recruited. The mean age of the participants was 86.58 (SD 10.31) and most were women (72%) and White (70%).

METHODS

This was a descriptive study, and a Rasch analysis was done to establish reliability based on internal consistency and evidence of differential item functioning (DIF) across races. Validity was based on item fit and model testing with structural equation modeling to compare models between White and Black participants.

RESULTS

There was evidence of internal consistency (alpha coefficient of 0.98) and no significant evidence of DIF. The item related to suicide had a high logit and did not significantly load onto the measurement model for Black individuals. There was not a good spread of the items across the concept of depression. The model had a better fit with the items when used with White versus Black participants.

CONCLUSIONS AND IMPLICATIONS

The findings indicate that it would be helpful to add some additional items that reflect depressive symptoms among this population. Further, the findings serve as a reminder that this measure may be biased toward identification of symptoms of depression among White versus Black residents.

Differences in Care Provided in Urban and Rural Nursing Homes in the United States: Literature Review

Despite evidence acknowledging disadvantages in care provided to older adults in rural nursing homes (NHs) in the United States, since 2010, no literature review has focused on differences in care provided in urban versus rural NHs. In the current study, we examined these differences by searching U.S. English-language peer-reviewed articles published after 2010 on differences in care quality in urban and rural NHs. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and used the Newcastle-Ottawa Scale for quality appraisal. We conducted full-text abstraction of 56 (of 286) articles, identifying 10 relevant studies. Metric specification of urban/rural location varied, and care quality measures were wide-ranging, making it difficult to interpret evidence. Limited evidence supported that rural NHs, compared to urban NHs, provided sparse mental health support and limited access to hospice care after controlling for facility and resident characteristics. Our review highlights the need for more research examining differences in quality of care between urban and rural NHs and raises several issues in current research examining urban/rural NH differences where future work is needed. [Journal of Gerontological Nursing, 47(12), 48-56.].

Healthy days at home: A population-based quality measure for cancer patients at the end of life

BACKGROUND

Healthy Days at Home (HDAH) is a novel population-based outcome measure. In this study, its use as a potential measure for cancer patients at the end of life (EOL) was explored.

METHODS

Patient demographics and health care use among Medicare beneficiaries with cancer who died over the years 2014 to 2017 were identified. The HDAH was calculated by subtracting the following components from 180 days: number of days spent in inpatient and outpatient hospital observation, the emergency room, skilled nursing facilities (SNF), inpatient psychiatry, inpatient rehabilitation, long-term hospitals, and inpatient hospice. How HDAH and its components varied by beneficiary demographics and health care market were evaluated. A patient-level linear regression model with HDAH as the outcome, hospital referral region (HRR) random effects, and market fixed effects were specified, as well as beneficiary age, sex, and comorbidities as covariates.

RESULTS

The 294,751 beneficiaries at the EOL showed a mean number of 154.0 HDAH (out of 180 days). Inpatient (10.7 days) and SNF (9.7 days) resulted in the most substantial reductions in HDAH. Males had fewer adjusted HDAH (153.1 vs 155.7, P < .001) than females; Medicaid-eligible patients had fewer HDAH compared with non-Medicaid-eligible patients (152.0 vs 154.9; P < .001). Those with hematologic malignancies had the fewest number of HDAH (148.9). Across HRRs, HDAH ranged from 10.8 fewer to 10.9 more days than the national mean. At the HRR-level, home hospice was associated with greater HDAH, whereas home health was associated with fewer HDAH.

CONCLUSIONS

HDAH may be a useful measure to understand, quantify, and improve patient-centered outcomes for cancer patients at EOL.