Terminal Hospitalizations of Nursing Home Residents: Does Facility Increasing the Rate of Do Not Resuscitate Orders Reduce Them?

Abstract

Context Terminal hospitalizations are costly and often avoidable with appropriate advance care planning. Objectives This study examined the association between advance care planning, as measured by facility rate of do not resuscitate (DNR) orders in U.S. nursing homes (NHs) and changes in terminal hospitalization rates. Methods Retrospective cohort study of the changing prevalence of DNR orders in U.S. NHs. Using a fixed effect multivariate model, we examined whether increasing facility rate of DNR orders correlates with reductions in terminal hospitalizations in the last week of life, controlling for changes in facility characteristics (staffing, use of NP/PA, case mix of nursing residents, admission volume, racial composition, payer mix). Results The average facility rate of terminal hospitalizations was 15.5%, fluctuating between 1999 (15.0%) and 2007 (14.8%). NHs starting with low rates of DNR orders that increased their rates had fewer terminal hospital admissions in 2007 (11.2%) than facilities with continuously low DNR usage. Even after applying a multivariate fixed effect model, the effect of changes in facility DNR order rate on terminal hospitalization was −0.056 (95% confidence interval: −0.061, −0.050), indicating that for every 10% increase in DNR orders there was 0.56% decrease in terminal hospitalizations. This rate can be compared with the increase of 0.70% in the terminal hospitalization rate when an NH became disproportionately dependent on Medicaid funding or the 0.40% decrease in terminal hospitalization rate associated with adding a nurse practitioner to the clinical staff complement. Conclusion NHs that changed their culture of decision making by increasing their facility rate of DNR orders decreased their rate of terminal hospitalizations.

Provider Staffing Effect on a Decision Aid Intervention

“…Facilities with full-time NP/PA staffing had significantly lower tube feeding rates, fewer deficiencies, and higher percentages of documented DNR orders (Table 2), suggesting higher quality of care in these facilities. This association between better outcomes and NP staffing is consistent with other studies (Bakerjian, 2008; Kane et al, 1991; Mitchell et al, 2003; Teno et al, 2011). …”

“…This may have been due to the high background rates of discussion present in our sample of nursing homes, reflected by a rate of 41% in control sites with full-time NP/PA staffing. NPs and PAs may be more likely to provide expert education, and engage surrogates and residents in discussions about goals of care, including discussions of feeding options, which is consistent with findings from other studies (Teno et al, 2011; Bourbonniere & Evans, 2002). This more intensive interaction may result in more frequent or more in-depth discussions about treatment preferences which, in turn, may limit the need for clinical communication tools such as decision aids.…”

“…NPs and PAs have similar roles in nursing homes despite important differences in their educational preparation, regulation by professional organizations, and state laws (Intrator et al, 2005; Mittman, Cawley, & Fenn, 2002). These two provider types are often viewed as one group by regulatory bodies and researchers (American Academy of Phyiscian Assistants, 2011; Intrator et al, 2005; Teno et al, 2011) In addition to evaluating residents and directing treatment, these providers also meet with residents’ families to discuss concerns and answer questions regarding residents’ health status and care (American Medical Directors Association, 2011; American Academy of Physician Assistants, 2011; Mittman et al, 2002). Additionally, NPs provide extensive education to residents, their families, and staff members and they spend more time overall with residents than physicians (Bakerjian, 2008; Bourbonniere & Evans, 2002).…”

Advance Directives and Care Received by Older Nursing Home Residents

“…16 In long-term care nursing home residents, higher rates of do-not-resuscitate orders (as a measure of ACP) resulted in lower rates of terminal hospitalizations. 17 Whether hospitalization of residents with comfort oriented ADs in our sample was in part due to change in goals for care or lack of ability to provide comfort care and symptom management within the NH is a plausible consideration, but from our study design and data we are not able to glean reasons for resident transfer to the hospital in enough granularity to report on this further.…”

Medicaid Reimbursement and the Quality of Nursing Home Care: A Case Study of Medi-Cal Long-Term Care Reimbursement Act of 2004 in California

“…Facilities with higher percentages of Medicaid residents have been found to be associated with more deficiencies [38][39], higher odds of hospitalization [40][41], more complaints [42], higher likelihood of voluntary or involuntary terminations [39,43], higher rates of antipsychotic medication prescription [39,44], and higher rates of physical restraint use and pressure ulcers [39]. Nursing homes with higher proportions of black residents and rural nursing homes also exhibited worse processes and outcomes [45][46][47].…”