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. 2024 Mar 4;7(3):e242546.
doi: 10.1001/jamanetworkopen.2024.2546.

Clinicians Who Practice Primarily in Nursing Homes and the Quality of End-of-Life Care Among Residents

Arnab K Ghosh  1 , Mark Aaron Unruh  2 , Hyunkyung Yun  3 , Hye-Young Jung  2
Affiliations

Clinicians Who Practice Primarily in Nursing Homes and the Quality of End-of-Life Care Among Residents

Arnab K Ghosh et al. JAMA Netw Open. .

Abstract

Importance: Clinician specialization in the care of nursing home (NH) residents or patients in skilled nursing facilities (SNFs) has become increasingly common. It is not known whether clinicians focused on NH care, often referred to as SNFists (ie, physicians, nurse practitioners, and physician assistants concentrating their practice in the NH or SNF setting), are associated with a reduced likelihood of burdensome transitions in the last 90 days of life for residents, which are a marker of poor-quality end-of-life (EOL) care.

Objective: To quantify the association between receipt of care from an SNFist and quality of EOL care for NH residents.

Design, setting, and participants: This cohort study analyzed Medicare fee-for-service claims for a nationally representative 20% sample of beneficiaries to examine burdensome transitions among NH decedents at the EOL from January 1, 2013, through December 31, 2019. Statistical analyses were conducted from December 2022 to June 2023.

Exposure: Receipt of care from an SNFist, defined as physicians and advanced practitioners who provided 80% or more of their evaluation and management visits in NHs annually.

Main outcomes and measures: This study used augmented inverse probability weighting in analyses of Medicare fee-for-service claims for a nationally representative 20% sample of beneficiaries. Main outcomes included 4 measures of burdensome transitions: (1) hospital transfer in the last 3 days of life; (2) lack of continuity in NHs after hospitalization in the last 90 days of life; (3) multiple hospitalizations in the last 90 days of life for any reason or any hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis; and (4) any hospitalization in the last 90 days of life for an ambulatory care-sensitive condition.

Results: Of the 2 091 954 NH decedents studied (mean [SD] age, 85.4 [8.5] years; 1 470 724 women [70.3%]), 953 722 (45.6%) received care from SNFists and 1 138 232 (54.4%) received care from non-SNFists; 422 575 of all decedents (20.2%) experienced a burdensome transition at the EOL. Receipt of care by an SNFist was associated with a reduced risk of (1) hospital transfer in the last 3 days of life (-1.6% [95% CI, -2.5% to -0.8%]), (2) lack of continuity in NHs after hospitalization (-4.8% [95% CI, -6.7% to -3.0%]), and (3) decedents experiencing multiple hospitalizations for any reason or any hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis (-5.8% [95% CI, -10.1% to -1.7%]). There was not a statistically significant association with the risk of hospitalization for an ambulatory care-sensitive condition in the last 90 days of life (0.0% [95% CI, -14.7% to 131.7%]).

Conclusions and relevance: This study suggests that SNFists may be an important resource to improve the quality of EOL care for NH residents.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Unruh reported receiving grants from Arnold Ventures, the National Institute on Aging, and the New York eHealth Collaborative; receiving personal fees from the American College of Physicians, the Agency for Healthcare Research and Quality, Brown University, and Chung-Ang University; and serving as an unpaid member of the Moving Forward Nursing Home Quality Coalition during the conduct of the study. Dr Jung reported receiving personal fees from Chung-Ang University during the conduct of the study. No other disclosures were reported.

References

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