Change in End-of-Life Care for Medicare Beneficiaries Site of Death, Place of Care, and Health Care Transitions in 2000, 2005, and 2009
- Joan M. Teno, MD, MS; Pedro L. Gozalo, PhD; Julie P. W. Bynum, MD, MPH; Natalie E. Leland, PhD; Susan C. Miller, PhD, MBA; Nancy E. Morden, MD, MPH; Thomas Scupp, BS; David C. Goodman, MD; Vincent Mor, PhD
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. 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. This period saw other changes in the "site of death": nursing homes increased by 7% and acute care hospitals decreased by 14%. At the same time, the use of hospices and hospital-based palliative care services 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,in actuality, most die in an institutional setting.One study found poorer quality of care in the institutional setting compared with care at home, especially with hospice services. The place of care and site of death have implications for the grief and posttraumatic stress disorders experienced by family members.
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.
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