This randomized clinical trial at 12 community-based nursing homes finds that a multimodal targeted infection program intervention reduced the rates of multidrug-resistant organisms and device-related infections in high-risk nursing home residents with indwelling devices. See the Invited Commentary by Stone.
Goldfeld et al compare the patterns of care and quality outcomes observed with Medicare and fee-for-service insurance programs on the care of nursing home patients with advanced dementia. Hall provides an invited commentary.
Nursing home residents with advanced dementia commonly experience burdensome and costly interventions (eg, tube feeding) that may be of limited clinical benefit. To our knowledge, Medicare expenditures have not been extensively described in this population.
Nursing home residents with advanced dementia in 22 facilities (N = 323) were followed up for 18 months. Clinical and health services use data were collected every 90 days. Medicare expenditures were described. Multivariate analysis was used to identify factors associated with total 90-day expenditures for (1) all Medicare services and (2) all Medicare services excluding hospice.
Over an18-month period, total mean Medicare expenditures were $2303 per 90 days but were highly skewed; expenditures were less than $500 for 77.1% of the 90-day assessment periods and more than $12 000 for 5.5% of these periods. The largest proportion of Medicare expenditures were for hospitalizations (30.2%) and hospice (45.6%). Among decedents (n = 177), mean Medicare expenditures increased by 65% in each of the last 4 quarters before death owing to an increase in both acute care and hospice. After multivariable adjustment, not living in a special care dementia unit was a modifiable factor associated with higher total expenditures for all Medicare services. Lack of a do-not-hospitalize order, tube feeding, and not living in a special care unit were associated with higher nonhospice Medicare expenditures.
Medicare expenditures among nursing home residents with advanced dementia vary substantially. Hospitalizations and hospice account for most spending. Strategies that promote high-quality palliative care may shift expenditures away from aggressive treatments for these patients at the end of life.