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Observational Study
. 2017 Jul;65(7):1406-1413.
doi: 10.1111/jgs.14891. Epub 2017 Apr 3.

End-of-Life Care Transition Patterns of Medicare Beneficiaries

Shi-Yi Wang  1   2 , Melissa D Aldridge  3   4 , Cary P Gross  2   5 , Maureen Canavan  6 , Emily Cherlin  6 , Elizabeth Bradley  6
Affiliations
Observational Study

End-of-Life Care Transition Patterns of Medicare Beneficiaries

Shi-Yi Wang et al. J Am Geriatr Soc. 2017 Jul.

Abstract

Objectives: To characterize the patterns of transitions in care and factors associated with multiple transitions in the last 6 months of life of U.S. decedents (N = 660,132).

Design: Retrospective study.

Setting: United States.

Participants: Medicare beneficiaries aged 66 and older who died from July to December 2011.

Measurements: Transitions between healthcare settings (e.g., hospital, skilled nursing facility, inpatient hospice, home hospice, home without hospice) in the last 6 months of life. A count variable for number of transitions was summarized, and Sankey diagrams were produced to illustrate the sequences of healthcare transitions. Multivariable analyses were used to identify factors associated with likelihood of having four or more transitions.

Results: More than 80% decedents (n = 556,437) had at least one transition within the last 6 months of life; 218,731 had four or more transitions within the last 6 months of life. The most-frequent transition pattern (19.3% of all decedents; n = 127,435) was home to hospital, back to home or skilled nursing facility, to hospital again, and then to settings other than hospital, ending with four or more transitions. The average number of transitions in the last 6 months of life varied substantially across states, ranging from 1.8 in Alaska to 3.1 in New Jersey. Transitions became more intensive for decedents approaching death. In multivariable analyses, women, blacks, individuals younger than 85, and individuals without dementia were more likely to have four or more transitions (all P < .05).

Conclusion: Approximately one-third of the Medicare beneficiaries who died in 2011 had four or more transitions within their last 6 months of life. Identifying interventions that can facilitate care transitions consistent with beneficiaries' preferences is warranted.

Keywords: Sankey diagram; end-of-life care; transitions in care.

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Conflict of interest statement

Financial Disclosures: Dr. Gross receives support from Medtronic, Inc., Johnson & Johnson, Inc., Pfizer, Inc., and 21st Century Oncology. These sources of support were not used for any portion of the current manuscript. None of the other coauthors have conflicts to report.

Figures

Figure 1
Figure 1
Unadjusted Mean Number of Care Transitions in the Last 6 Months of Life by State
Figure 2
Figure 2
Sequence of Care Transitions in the Last 6 Months of Life, for Medicare Decedents in the United States
Figure 3
Figure 3
Locations in the Last 6 Months of Life, for Medicare Decedents in Utah (A) and New Jersey (B)
See this image and copyright information in PMC

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