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To explore what nursing home resident demographic, clinical, functional, and health services utilization characteristics influence a “do not hospitalize” designation.
Historical cohort study.
Extended care residents in 2 hospital-based and 4 free-standing nursing homes who died between 2001 and 2007.
The designation of “do not hospitalize” on a resident’s chart.
Continuity of family physician care from admission to death (adjusted hazard ratio [AHR] 2.16, 95% confidence interval [CI] 1.33 to 3.49), a sudden and unexpected death (AHR 0.43, 95% CI 0.25 to 0.73), and age (AHR 1.02, 95% CI 1.01 to 1.02) were independently associated with a “do not hospitalize” designation.
The greater than 2-fold positive association of continuity of family physician care with a “do not hospitalize” designation is an interesting addition to the literature on how continuity of physician care matters.
Déterminer, chez des résidents de centres d’hébergement, quelles caractéristiques démographiques, cliniques, fonctionnelles et relatives à l’utilisation des services de santé influencent l’inscription « ne pas hospitaliser » au dossier.
Étude de cohorte historique.
Résidents en soins prolongés de 2 centres d’hébergement intra-hospitaliers et 4 extra-hospitaliers, qui sont décédés entre 2001 et 2007.
L’inscription « ne pas hospitaliser » au dossier du résident.
La mention « ne pas hospitaliser » était associée, de façon indépendante, à la continuité des soins du médecin de famille entre l’admission et le décès (rapport de risque ajusté [RRA] 2.16, intervalle de confiance [IC] à 95 % 1,33 – 3,49), à un décès soudain et inattendu (RRA 0,43, IC à 95 % 0,25–0,73) et à l’âge (RRA 1,02, IC à 95 % 1,01–1,02).
Cette corrélation positive par un facteur supérieur à 2 entre la continuité des soins du médecin de famille et la mention « ne pas hospitaliser » contribue de façon intéressante à la littérature sur l’importance de la continuité des soins du médecin.
Nursing homes (long-term care facilities) provide residential care to frail elders no longer able to care for themselves or live independently. Many nursing home residents are at the end of their lives, and the average length of stay for extended care residents (ie, the most functionally dependent residents) in one Canadian province was reported to be approximately 18 months.1 Advanced directives, or some form of a written statement providing a caregiver with an indication of how aggressively an individual wishes to be treated at the end of life, have been associated with both a higher frequency of death outside of hospital2 and a lower frequency of hospital admissions.3,4 Given that avoidance of unwanted life support was found to be one important element related to high-quality end-of-life care among seriously ill patients and their family members,5 the presence of advanced directives in frail nursing home populations is especially relevant. Research in this area has shown mixed results as to whether individual demographic (eg, age, sex, ethnicity) and health status (eg, mental capacity, severity of illness) factors are associated with variation in advanced directives6,7 and ultimate place of death (in the nursing home vs in hospital).6
In British Columbia, most (70%) nursing homes are publicly funded, non-profit institutions, and virtually the entire resident population is long-stay.8 One in 5 of the province’s approximately 300 nursing homes is either physically or administratively attached to a hospital (hospital-based) and the rest are free-standing facilities.8 From the time of admission to facilities, residents have designated degrees of intervention on their charts to indicate how aggressively they should be medically treated if they become ill. Degrees of intervention are a series of predefined choices that are less individualized than advanced directives: Degree 1 directs caregivers to manage illness with palliation on-site. Degree 2 directs caregivers to manage illness with curative medical treatment within the confines of the nursing home. Degree 3 indicates hospitalization for acute illness without cardiopulmonary resuscitation, and degree 4 indicates hospitalization with full cardiopulmonary resuscitation (Table 1). Degrees of intervention are updated on a yearly basis by the family physician in consultation with the resident and his or her family.
Our study question asked the following: “Among a cohort of decedent nursing home residents at the frailest (extended) level of care, what demographic, clinical, functional, and health services utilization characteristics were associated with a ‘do not hospitalize’ (degrees of intervention 1 or 2) designation on the chart?”
This was a historical cohort study of extended level of care nursing home residents who died between 2001 and 2007. Charts were reviewed from a convenience sample of 2 hospital-based and 4 free-standing publicly funded, non-profit facilities in Vancouver, BC. Sample size calculations were based on finding a difference in effect size of 40% versus 55% between the 2 facility groups at 5% 2-sided significance and 80% power. In the hospital-based facilities, extended care status was a requirement of admission. In free-standing facilities, residents might have been admitted to the facility at a higher functional level (intermediate care). After experiencing further functional decline, these residents would then be re-classified at an extended care functional level. We selected the charts of extended care residents only, as we wanted to compare residents at similar functional levels. We counted these residents as being “admitted” to extended care on the date they were deemed by the public funder to be at an extended level of care. Documentation for this was found in the clinical chart notes, and because a higher level of funding is attached to extended care status, this date was generally well recorded.
Chart reviews were performed by 3 individuals using a common data collection instrument, and regular interrater reliability evaluation demonstrated greater than 90% agreement among the individuals. Ethics approval was obtained from the University of British Columbia Clinical Research Ethics Board and the relevant Vancouver Coastal Health Authority acute and community ethical review boards.
We collected data on the following resident demographic characteristics: age at the time of admission to extended care, sex, and whether the resident was married and his or her partner was alive at the time of death. We collected data on clinical characteristics (ie, individual and sum of Charlson comorbidities9; presence or absence of a sudden and unexpected death; and number of prescription medications) and functional characteristics (ie, individual and sum of pressure ulcers; indwelling bladder catheter; wheelchair dependency; dependence on others for feeding; and requiring a mechanical lift for transfers) present at the time of death. We collected data on the residents’ use of the following health services: the number of visits to the hospital emergency department (ED) in the 3 months before death; the presence or absence of hospital admissions in the 3 months before death; death in the facility (vs hospital); the number of family physician visits in the 3 months before death; and continuity of family physician care measured by whether it was the same treating physician at the time of admission and at the time of death. Finally, residence in a hospital-based versus free-standing facility was also measured.
The dates, status, and all changes in residents’ degrees of intervention were recorded from the time of admission until death. Residents’ degrees of intervention were aggregated into “do not hospitalize” (degrees of intervention 1 and 2) versus “hospitalize” (degrees of intervention 3 and 4). We calculated the time period each resident had a “hospitalize” designation on his or her chart from the time of admission into extended care until either death or a change to “do not hospitalize.” This time then constituted the time period that each resident was “at risk” of a “do not hospitalize” designation.
We generated descriptive statistics on all collected variables. We also examined associations between “do not hospitalize” designations at the time of death and the use of health services and the demographic, clinical, and functional variables using 2-way tests of comparison.
We used Cox regression analysis, with “time to ‘do not hospitalize’” as our end point, as the aim of this study was to explore the correlates of a “do not hospitalize” designation for nursing home residents. This analysis allowed us to account for the different time periods during which each resident had “the opportunity” to acquire a “do not hospitalize” designation. Death occurring before a “do not hospitalize” designation was a censoring event.
Residents’ use of health services and demographic, clinical, and functional variables demonstrating an association with “do not hospitalize” at the time of death of P ≤ .05 in the 2-way tests of comparison were entered into a univariable Cox regression model. These variables were then assessed in a multivariable Cox regression model using a backward stepwise approach. Standard errors were adjusted for analysis of facility effects within hospital-based and free-standing groups. Variables with an association of P ≤ .05 were retained in the final model.
In cases where explanatory variables were highly correlated (eg, hospital visit and hospital ED visit), only the variable with the strongest association was considered a candidate variable in the multivariable model. Death within the facility was similarly not included in the model owing to its high degree of correlation with the outcome variable (ie, “do not hospitalize”). The proportional hazards assumption was assessed using log-minus-log graphing for the main effect of interest (hospital-based vs free-standing).
We used SPSS version 16.0 to generate the descriptive statistics and Intercooled Stata version 9.2 for Windows to perform the regression modeling.
We reviewed the charts of 369 decedent extended care residents. The most prevalent Charlson comorbidity among residents was dementia (72%) followed by cerebrovascular disease (42%). The most prevalent debility was wheelchair dependence (86%), and half of all residents (50%) required mechanical lifts for transfers. Forty-two percent of residents required total feeding assistance, approximately one-third (31%) had documentation of bed sores or wounds, and 1 out of 10 residents (10%) had an indwelling bladder catheter.
Although half of residents received “do not hospitalize” designations within 2 weeks of admission (median 2.0 weeks), the interquartile range for time to the “do not hospitalize” designation was 53 weeks. Virtually all residents with “do not hospitalize” designations at the time of death died in the nursing home (317 of 321 [98.8%] residents). Approximately one-third (32.4%) of residents were admitted to the hospital or the hospital ED in the 3 months before death. Additional results for the descriptive analyses are presented in Table 2.
In the multivariable Cox regression model, continuity of family physician care from admission to death (adjusted hazard ratio [AHR] 2.16, 95% confidence interval [CI] 1.33 to 3.49), a sudden and unexpected death (AHR 0.43, 95% CI 0.25 to 0.73), and age (AHR 1.02, 95% CI 1.01 to 1.02) were independently associated with a “do not hospitalize” designation (Table 3). Female sex (HR 1.15, 95% CI 1.05 to 1.25) and residence in a hospital-based facility (HR 1.21, 95% CI 1.01 to 1.45) were positively associated with a “do not hospitalize” designation in the univariable analysis. However, these variables dropped out owing to non-significance in the multivariable model. Finally, the number of physician visits had a very small but statistically significant effect in the adjusted model (AHR 1.01, 95% CI 1.00 to 1.03).
This study examined the individual and health services utilization characteristics associated with a “do not hospitalize” designation, in a sample of debilitated nursing home residents. A key finding was the association of continuity of family physician care with a greater than 2-fold AHR of a “do not hospitalize” designation. Continuity in primary care, defined as the relationship between a single practitioner and a patient extending beyond isolated encounters for episodic illness, has been expressed as “an implicit contract of loyalty by the patient and clinical responsibility by the provider.”10 Previous research has found that patients highly value a relationship with primary care physicians, particularly in the context of more serious psychological and family issues.11 The value placed on this relationship has been found to increase with extremes of age and number of chronic conditions.12 In a population of frail institutionalized elders where both these characteristics are highly prevalent, continuity of the resident-physician relationship is therefore likely to be of value to residents and family. It is possible that with continuity comes greater confidence of the family physician to openly discuss end-of-life issues. It is also possible that residents and their families have greater confidence that a decision to not hospitalize will not imply a decision to stop providing care within the facility. Regardless of the mechanism, the association of continuity of family physician care with a “do not hospitalize” designation suggests that policies promoting continuity of physician care in nursing home settings are likely to support decreased rates of hospitalization and dying in hospital.2,13,14
Sudden and unexpected death was associated with a greater than 2-fold lower AHR of “do not hospitalize.” This finding is presumably explained by caregivers being less likely to initiate end-of-life discussions with residents who are not observed to be on obvious trajectories of decline and for whom death is a sudden and unexpected event. While the overall proportion of residents with a sudden and unexpected death was relatively small (8.7%), it nonetheless underscores the need to engage in such discussions early on, given the clinical frailty of this population.
Although the study found that half of all extended care residents had a relatively short period of time (median 2.0 weeks) during which they had “hospitalize” designations, there was a range of time during which other residents retained their “hospitalize” designations. Furthermore, approximately 1 in 3 residents was transferred to hospital EDs or experienced hospital admissions in the 3 months before death. There is growing literature demonstrating further decline15 and medical futility15–17 associated with hospitalization of nursing home populations. There is also evidence that in-place treatment of nursing home residents for conditions like pneumonia actually produces better outcomes.18 Policies that encourage proactive discussions of end-of-life care between nursing home residents (or their families) and caregivers would therefore seem to be especially important in this setting.
A weakness of this study was that we were unable to explore cultural and religious characteristics that might have influenced “do not hospitalize” decisions owing to the poor data quality on these variables. Although the model adjusted for facility-level effects, we did not measure more precise facility characteristics (regularly scheduled information nights for residents and their families about degrees of intervention, written handouts on the topic, etc) that might have influenced “do not hospitalize” conversations. It should also be noted that the censoring event (death) in the Cox regression analysis was informative (vs noninformative). Furthermore, as with all retrospective studies, missing data and misclassification might have resulted in unintended bias or confounding.
To our knowledge there has been little prior quantitative research in this study population and none that implemented a Cox regression approach with a “do not hospitalize” designation as the end point. Moreover, the finding that continuity of family physician care was positively associated with a “do not hospitalize” designation contributes to the literature on how continuity of physician care “matters” and sheds some light on the factors influencing variation in “do not hospitalize” designations among a sample of frail nursing home residents
Dr McGregor has received a Community-based Clinician Investigator award, which is funded through the Vancouver Foundation, and she is further supported by the University of British Columbia (UBC) Centre for Health Services and Policy Research, as well as the UBC Department of Family Practice, Division of Geriatrics. Mr Pare was funded by the UBC Summer Student Research Program, 2007. The study was further funded by grants from the UBC Department of Family Practice, Division of Geriatrics, and the Vancouver General Hospital, Department of Family Practice. We gratefully acknowledge the following individuals: M. Schulzer, UBC Department of Statistics, who contributed to the initial study design and data analysis; K. Cardiff, research associate, who assisted with chart data abstraction; the Directors of Care, including J. Globerman, L. Wentland, C. Lusk, and J. Nolin, who supported us in performing the data abstraction; personnel from medical records of the relevant hospital departments, including J. Croucher, S. Power, J. Kenyon, and L. O’Brien, who supported us in performing chart abstraction of hospital-based facilities.
This article has been peer reviewed.
Cet article a fait l’objet d’une révision par des pairs.
Dr McGregor was responsible for the conception and design of the study and initially drafted the manuscript. Mr Pare and Ms Wong contributed to the acquisition of data. All authors contributed to data interpretation, manuscript revision, and gave final approval of the version to be published.