新作坊

Change in End-of-Life Care for Medicare Beneficiaries Site of Death, Place of Care, and Health Care Transitions in 2000, 2005, and 2009

摘要：

Importance A recent Centers for Disease Control and Prevention report found that more persons die at home. This has been cited as evidence that persons dying in the United States are using more supportive care. Objective To describe changes in site of death, place of care, and health care transitions between 2000, 2005, and 2009. Design, Setting, and Patients Retrospective cohort study of a random 20% sample of fee-for-service Medicare beneficiaries, aged 66 years and older, who died in 2000 (n = 270 202), 2005 (n = 291 819), or 2009 (n = 286 282). A multivariable regression model examined outcomes in 2000 and 2009 after adjustment for sociodemographic characteristics. Based on billing data, patients were classified as having a medical diagnosis of cancer, chronic obstructive pulmonary disease, or dementia in the last 180 days of life. Main Outcome Measures Site of death, place of care, rates of health care transitions, and potentially burdensome transitions (eg, health care transitions in the last 3 days of life). Results Our random 20% sample included 848 303 fee-for-service Medicare decedents (mean age, 82.3 years; 57.9% female, 88.1% white). Comparing 2000, 2005, and 2009, the proportion of deaths in acute care hospitals decreased from 32.6% (95% CI, 32.4%-32.8%) to 26.9% (95% CI, 26.7%-27.1%) to 24.6% (95% CI, 24.5%-24.8%), respectively. However, intensive care unit (ICU) use in the last month of life increased from 24.3% (95% CI, 24.1%-24.5%) to 26.3% (95% CI, 26.1%-26.5%) to 29.2% (95% CI, 29.0%-29.3%). (Test of trend P value was <.001 for each variable.) Hospice use at the time of death increased from 21.6% (95% CI, 21.4%-21.7%) to 32.3% (95% CI, 32.1%-32.5%) to 42.2% (95% CI, 42.0%-42.4%), with 28.4% (95% CI, 27.9%-28.5%) using a hospice for 3 days or less in 2009. Of these late hospice referrals, 40.3% (95% CI, 39.7%-40.8%) were preceded by hospitalization with an ICU stay. The mean number of health care transitions in the last 90 days of life increased from 2.1 (interquartile range [IQR], 0-3.0) to 2.8 (IQR, 1.0-4.0) to 3.1 per decedent (IQR, 1.0-5.0). The percentage of patients experiencing transitions in the last 3 days of life increased from 10.3% (95% CI, 10.1%-10.4%) to 12.4% (95% CI, 12.3%-2.5%) to 14.2% (95% CI, 14.0%-14.3%). Conclusion and Relevance Among Medicare beneficiaries who died in 2009 and 2005 compared with 2000, a lower proportion died in an acute care hospital, although both ICU use and the rate of health care transitions increased in the last month of life. Public opinion surveys in the United States report that a majority of people would prefer to die at home if they were terminally ill.1 Data indicate an increase in the percentage of people dying at home among those aged 65 years and older, from 15% in 1989 to 24% in 2007.2 This period saw other changes in the “site of death”: nursing homes increased by 7% and acute care hospitals decreased by 14%.2 At the same time, the use of hospices3 and hospital-based palliative care services4 expanded. Is this evidence of the success of hospice- and hospital-based palliative care teams? Site of death has been proposed as a quality measure for end-of-life care because, despite general population surveys indicating the majority of respondents and those with serious illness want to die at home,5 in actuality, most die in an institutional setting.2,6 One study found poorer quality of care in the institutional setting compared with care at home, especially with hospice services.7 The place of care and site of death have implications for the grief and posttraumatic stress disorders experienced by family members.8 Site of death, as noted on a death certificate, only provides information on where a person was at the moment of death. One patient may have spent the last week of life in a home, hospital, and nursing home, while another patient may have been at home until the day of death, when hospitalized for pain control. Both patients would have an identical site of death, but a convincing argument can be made that the experience was different. To provide a more thorough assessment of end-of-life care, we analyzed Medicare claims data for 2000, 2005, and 2009 to document places of care and health care transitions for Medicare decedents in the last months of life.