Trends and Patterns in Place of Death for Nursing Home Residents: CY2003-2007

Americans increasingly die in nursing homes (NHs), but little is known about their end-of-life (EOL) care. This study: 1) explores longitudinal and cross-sectional variations in hospitalizations among NH decedents; 2) describes associated Medicare spending; and 3) examines the association between hospice use, presence of advance directives and in-hospital deaths for NH residents.

The Minimum Data Set (MDS), Medicare Denominator, Inpatient Hospital, and Hospice claims were used. The study population includes 2,530,680 decedents in 16,000+ facilities, over a 5-year period (CY2003-2007).

The proportion of residents who were transferred to hospitals and who died there remained stable at slightly over 20% each year. The proportion of decedents receiving hospice prior to death increased, from 25.4% in 2003 to 36.9% in 2007. Considerable cross-sectional variations in hospice use and place of death continue to persist. For example, in 2007, the proportion of long-term residents who died in a hospital ranged from less than 5% in Utah to over 30% in Mississippi and the District of Columbia. In 2007, Medicare spent over $943 million on hospitalizations incurred by these decedents in the last 30 days of life alone, 50% of which is attributable to hospitalizations ending in death. Our findings suggest that individuals' treatment preferences such as hospice use and presence of advance directives maybe associated with fewer hospital deaths and lower Medicare costs.

The current health reform debate includes discussions about EOL care. Anecdotal evidence has suggested that NHs often transfer dying residents to hospitals. This study offers evidence to inform this debate.