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Burdensome Transitions Impact End-of-Life Care Quality

Health care transitions tied to higher rates of feeding tubes, ICU stays, stage IV decubitus ulcer

WEDNESDAY, Sept. 28 (HealthDay News) -- Burdensome health care transitions in the last months of life are common and are associated with poor quality end-of-life care, according to a study published in the Sept. 29 issue of the New England Journal of Medicine.

Pedro Gozalo, Ph.D., from Brown University in Providence, R.I., and colleagues investigated health care transitions among 474,829 nursing home residents with advanced cognitive and functional impairment 120 days before death. Three types of transitions were classified as being burdensome: those occurring in the last three days of life, absence of nursing home continuity following hospitalization during the last 90 days of life, or multiple hospitalizations in the last 90 days of life. The associations between regional rates of burdensome transitions and the likelihood of feeding-tube insertion, hospitalization in an intensive care unit (ICU) in the last month of life, the presence of a stage IV decubitus ulcer, and hospice enrollment in the last three days of life were assessed.

The investigators found that 19 percent of the patients had at least one burdensome transition, with variation across states (range, 2.1 to 37.5 percent). Blacks, Hispanics, and those without advance directives had an increased risk of burdensome transition. Compared to patients in the lowest quintile of burdensome transitions, those in the highest quintile had significantly increased rates of feeding-tube insertion (adjusted risk ratio [aRR], 3.38), ICU time in the last month of life (aRR, 2.10), late hospice enrollment (aRR 1.17), and a stage IV decubitus ulcer (aRR, 2.28).

"We suggest that the measurement of burdensome transitions can be used to monitor the quality of end-of-life care in health systems," the authors write.

One author disclosed consulting relationships with long-term care and nursing home organizations.

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