Hospice Utilization in Nursing Homes: Association With Facility End-of-Life Care Practices

Nursing homes (NHs) have become a common site where older Americans live and die. About 25% Americans die in NHs (Gruneir et al., 2007; National Center for Health Statistics, 2008; Weitzen, Teno, Fennell, & Mor, 2003). Despite of their growing importance in providing end-of-life (EOL) care, the quality of EOL care in NHs is often inadequate. Prior studies have suggested that NH residents at the EOL may not receive adequate symptom management, are frequently and often inappropriately transferred to hospitals, and are likely to receive invasive procedures (e.g., feeding tubes) that lack clinically proven benefits at the EOL (Gessert, Haller, Kane, & Degenholtz, 2006; Mukamel et al., 2012; Saliba et al., 2000; Teno et al., 2004; Teresi, Abrams, Holmes, Ramirez, & Eimicke, 2001; Travis, Loving, McClanahan, & Bernard, 2001). Hospice has been viewed as a mechanism for improving the quality of EOL care. NH residents receiving hospice care have been shown to have lower risk of hospitalization and higher probability of receiving pain management in accordance with clinical guidelines (Gozalo & Miller, 2007; Miller, Mor, & Teno, 2003). Families reported that their loved ones’ physical symptoms and emotional needs were better addressed after hospice enrollment (Baer & Hanson, 2000). The prevalence of hospice use in NHs has increased from less than 10% in 1996 to 33% in 2006 (Miller, Lima, Gozalo, & Mor, 2010; Miller & Mor, 2001, 2004). Despite this growth, the rate of hospice use in NHs remains generally low and varies substantially across states and across facilities (Miller et al., 2010; Petrisek & Mor, 1999; Zerzan, Stearns, & Hanson, 2000). In addition, many hospice users do not enroll in hospice until very close to death, which may not allow sufficient time to effectively manage their symptoms and to meet their care needs (Miller, Mor, et al., 2003; Miller, Teno, & Mor, 2004). More than one third of NH hospice enrollees use hospice for a week or less, and about 16% of hospice stays last no more than 3 days (Huskamp, Stevenson, Grabowski, Brennan, & Keating, 2010; Miller, Weitzen, & Kinzbrunner, 2003). The prevalence of such short stays has increased significantly over time (Miller, Weitzen, et al., 2003). Studies have identified several categories of factors associated with hospice use in NHs: individual characteristics (e.g., health and demographic factors, treatment restrictions and preferences), state policies (e.g., Medicaid case-mix reimbursement, hospice certificate of need), facility characteristics and market attributes (e.g., ownership, staffing, hospital and hospice supply) (Christakis & Iwashyna, 2000; Huskamp et al., 2010; Iwashyna, Chang, Zhang, & Christakis, 2002; Miller et al., 2010; Miller & Mor, 2004; Petrisek & Mor, 1999), and rural–urban locations(Temkin-Greener, Zheng, & Mukamel, 2012). However, to our knowledge, no study has yet examined the effect of EOL care practice style on residents’ hospice utilization. Compared with facility structural attributes, practice styles may be more mutable and, therefore, represent better opportunities for increasing hospice utilization in NHs. The objective of this study was to address this gap in the literature by answering the following questions: (a) Is NH’s self-reported tendency to offer hospice to EOL residents an independent factor associated with residents’ hospice utilization? (b) Is NH’s self-reported tendency to initiate aggressive treatments (hospital transfers and feeding tubes) independently associated with residents’ hospice utilization?