@article {7703, title = {Disability and decline in physical function associated with hospital use at end of life.}, journal = {J Gen Intern Med}, volume = {27}, year = {2012}, month = {2012 Jul}, pages = {794-800}, publisher = {27}, abstract = {

BACKGROUND: Hospital use near the end of life is often undesirable to patients, represents considerable Medicare cost, and varies widely across regions.

OBJECTIVE: To concurrently examine regional and patient factors, including disability and functional decline, associated with end-of-life hospital use.

DESIGN/PARTICIPANTS: We sampled decedents aged 65 and older (n = 2,493) from the Health and Retirement Study (2000-2006), and linked data from individual Medicare claims and the Dartmouth Atlas of Health Care. Two-part regression models estimated the relationship between total hospital days in the last 6 months and patient characteristics including physical function, while adjusting for regional resources and hospital care intensity (HCI).

KEY RESULTS: Median hospital days was 7 (range = 0-183). 53\% of respondents had functional decline. Compared with decedents without functional decline, those with severe disability or decline had more regression-adjusted hospital days (range 3.47-9.05, depending on category). Dementia was associated with fewer days (-3.02); while chronic kidney disease (2.37), diabetes (2.40), stroke or transient ischemic attack (2.11), and congestive heart failure (1.74) were associated with more days. African Americans and Hispanics had more days (5.91 and 4.61, respectively). Those with family nearby had 1.62 fewer days and hospice enrollees had 1.88 fewer days. Additional hospital days were associated with urban residence (1.74) and residence in a region with more specialists (1.97) and higher HCI (2.27).

CONCLUSIONS: Functional decline is significantly associated with end-of-life hospital use among older adults. To improve care and reduce costs, health care programs and policies should address specific needs of patients with functional decline and disability.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, Chronic disease, Dementia, Disability Evaluation, Disabled Persons, Female, Frail Elderly, Geriatric Assessment, Hospitalization, Humans, Length of Stay, Longitudinal Studies, Male, Medicare, Socioeconomic factors, Terminal Care, United States}, issn = {1525-1497}, doi = {10.1007/s11606-012-2013-9}, author = {Amy Kelley and Susan L Ettner and R Sean Morrison and Qingling Du and Catherine A Sarkisian} } @article {7624, title = {Determinants of death in the hospital among older adults.}, journal = {J Am Geriatr Soc}, volume = {59}, year = {2011}, note = {Kelley, Amy S Ettner, Susan L Wenger, Neil S Sarkisian, Catherine A United States Journal of the American Geriatrics Society J Am Geriatr Soc. 2011 Dec;59(12):2321-5. doi: 10.1111/j.1532-5415.2011.03718.x. Epub 2011 Nov 8.}, month = {2011 Dec}, pages = {2321-5}, publisher = {59}, abstract = {

OBJECTIVES: To investigate patient-level determinants of in-hospital death, adjusting for patient and regional characteristics.

DESIGN: Using multivariable regression, the relationship between in-hospital death and participants{\textquoteright} social, functional, and health characteristics was investigated, controlling for regional Hospital Care Intensity Index (HCI) from the Dartmouth Atlas of Health Care.

SETTING: The Health and Retirement Study, a longitudinal nationally representative cohort of older adults.

PARTICIPANTS: People aged 67 and older who died between 2,000 and 2,006 (N~=~3,539) were sampled.

MEASUREMENTS: In-hospital death.

RESULTS: Thirty-nine percent (n~=~1,380) of participants died in the hospital (range 34\% in Midwest to 45\% in Northeast). Nursing home residence, functional dependence, and cancer or dementia diagnosis, among other characteristics, were associated with lower adjusted odds of in-hospital death. Being black or Hispanic, living alone, and having more medical comorbidities were associated with greater adjusted odds, as was higher HCI. Sex, education, net worth, and completion of an advance directive did not correlate with in-hospital death.

CONCLUSION: Black race, Hispanic ethnicity, and other functional and social characteristics are correlates of in-hospital death, even after controlling for the role of HCI. Further work must be done to determine whether preferences, provider characteristics and practice patterns, or differential access to medical and community services drive this difference.

}, keywords = {Aged, Aged, 80 and over, Female, Hospital Mortality, Humans, Male, Multivariate Analysis, Risk Factors, Socioeconomic factors}, issn = {1532-5415}, doi = {10.1111/j.1532-5415.2011.03718.x}, author = {Amy Kelley and Susan L Ettner and Neil S. Wenger and Catherine A Sarkisian} } @article {10887, title = {Determinants of medical expenditures in the last 6 months of life.}, journal = {Annals of Internal Medicine}, volume = {154}, year = {2011}, pages = {235-242}, abstract = {

BACKGROUND: End-of-life medical expenditures exceed costs of care during other years, vary across regions, and are likely to be unsustainable. Identifying determinants of expenditure variation may reveal opportunities for reducing costs.

OBJECTIVE: To identify patient-level determinants of Medicare expenditures at the end of life and to determine the contributions of these factors to expenditure variation while accounting for regional characteristics. It was hypothesized that race or ethnicity, social support, and functional status are independently associated with treatment intensity and controlling for regional characteristics, and that individual characteristics account for a substantial proportion of expenditure variation.

DESIGN: Using data from the Health and Retirement Study, Medicare claims, and The Dartmouth Atlas of Health Care, relationships were modeled between expenditures and patient and regional characteristics.

SETTING: United States, 2000 to 2006.

PARTICIPANTS: 2394 Health and Retirement Study decedents aged 65.5 years or older.

MEASUREMENTS: Medicare expenditures in the last 6 months of life were estimated in a series of 2-level multivariable regression models that included patient, regional, and patient and regional characteristics.

RESULTS: Decline in function (rate ratio [RR], 1.64 [95\% CI, 1.46 to 1.83]); Hispanic ethnicity (RR, 1.50 [CI, 1.22 to 1.85]); black race (RR, 1.43 [CI, 1.25 to 1.64]); and certain chronic diseases, including diabetes (RR, 1.16 [CI, 1.06 to 1.27]), were associated with higher expenditures. Nearby family (RR, 0.90 [CI, 0.82 to 0.98]) and dementia (RR, 0.78 CI, 0.71 to 0.87]) were associated with lower expenditures, and advance care planning had no association. Regional characteristics, including end-of-life practice patterns (RR, 1.09 [CI, 1.06 to 1.14]) and hospital beds per capita (RR, 1.01 [CI, 1.00 to 1.02]), were associated with higher expenditures. Patient characteristics explained 10\% of overall variance and retained statistically significant relationships with expenditures after regional characteristics were controlled for.

LIMITATION: The study limitations include the decedent sample, proxy informants, and a large proportion of unexplained variation.

CONCLUSION: Patient characteristics, such as functional decline, race or ethnicity, chronic disease, and nearby family, are important determinants of expenditures at the end of life, independent of regional characteristics.

PRIMARY FUNDING SOURCE: The Brookdale Foundation.

}, keywords = {Aged, Aged, 80 and over, Chronic disease, Ethnic Groups, Female, Health Expenditures, Humans, Income, Independent Living, Male, Medicare, Regression Analysis, Social Support, Socioeconomic factors, Terminal Care, United States}, issn = {1539-3704}, doi = {10.7326/0003-4819-154-4-201102150-00004}, author = {Amy Kelley and Susan L Ettner and R Sean Morrison and Qingling Du and Neil S. Wenger and Catherine A Sarkisian} }