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Original Investigation | Health Care Reform

Health Insurance Status and the Care of Nursing Home Residents With Advanced Dementia

Keith S. Goldfeld, DrPH, MS, MPA1; David C. Grabowski, PhD2; Daryl J. Caudry, MS2; Susan L. Mitchell, MD, MPH3,4
[+] Author Affiliations
1Department of Population Health, New York University School of Medicine, New York
2Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
3Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
4Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
JAMA Intern Med. 2013;173(22):2047-2053. doi:10.1001/jamainternmed.2013.10573.
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Importance  Nursing home residents with advanced dementia commonly experience burdensome and costly hospitalizations that may not extend survival or improve the quality of life. Fragmentation in health care has contributed to poor coordination of care for acutely ill nursing home residents.

Objective  To compare patterns of care and quality outcomes for nursing home residents with advanced dementia covered by managed care with those covered by traditional fee-for-service Medicare.

Design, Setting, and Participants  Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life (CASCADE) was a prospective cohort study including 22 nursing homes in the Boston, Massachusetts, area that monitored 323 nursing home residents for 18 months to better understand the course of advanced dementia at or near the end of life. Data from CASCADE and Medicare were linked to determine the health insurance status of study participants.

Exposures  The health insurance status of the resident, either managed care or traditional fee for service.

Main Outcomes and Measures  The outcomes included survival, symptoms related to comfort, treatment of pain and dyspnea, presence of pressure ulcers, presence of a do-not-hospitalize order, treatment of pneumonia, hospital transfer (admission or emergency department visit) for an acute illness, hospice referral, primary care visits, and family satisfaction with care.

Results  Residents enrolled in managed care (n = 133) were more likely to have do-not-hospitalize orders compared with those in traditional Medicare fee for service (n = 158) (63.7% vs 50.9%; adjusted odds ratio, 1.9; 95% CI, 1.1-3.4), were less likely to be transferred to the hospital for acute illness (3.8% vs 15.7%; adjusted odds ratio, 0.2; 95% CI, 0.1-0.5), had more primary care visits per 90 days (mean [SD], 4.8 [2.6] vs 4.2 [5.0]; adjusted rate ratio, 1.3; 95% CI, 1.1-1.6), and had more nurse practitioner visits (3.0 [2.1] vs 0.8 [2.6]; adjusted rate ratio, 3.0; 95% CI, 2.2-4.1). Survival, comfort, and other treatment outcomes did not differ significantly across groups.

Conclusions and Relevance  Medicare managed-care programs may offer a promising approach to ensure that nursing homes are able to provide appropriate, less burdensome, and affordable care, especially at the end of life.

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