Attributes of nursing home-hospice collaborations & end of life hospitalizations

描述(由申请人提供)：临终疗养院(NH)居民经常在生命的最后30天内住院，导致更糟糕的健康结果和高昂的医疗保险费用。虽然已经表明，临终关怀的使用导致临终关怀参与者的住院率较低，但尚不清楚NH-临终关怀协作的属性--特别是临终关怀使用量和协作的排他性(即，NH-临终关怀协作是否主要与一个或两个或更多提供者合作)--与所有NH临终关怀居民的住院治疗有关(NH-临终关怀协作也可能通过溢出效应使非临终关怀居民受益)。NH市场临终关怀提供者的快速增长和这种增长的巨大地理差异为我们提供了一个机会，来研究NH临终关怀协作属性的变化与临终(EOL)住院之间的关系。长期目标是了解可以用来改善临终居民姑息护理并降低成本的方法。这项研究的目的是了解NH-临终关怀协作的特定属性如何与NH的EOL住院相关。其基本原理是，这项研究将为进一步深入研究NH-临终关怀协作与EOL住院之间的因果关系铺平道路，并最终为所有濒临死亡的NH居民提供更好的临终姑息护理提供指导。利用2000-2009年的全国数据，本研究有两个目的。目的-1是通过在所有NH患者中检验以下2个假设来检验NH-临终关怀协作的属性与EOL住院之间的关系。(1)如果居民居住在临终关怀使用量较高的医院，则在生前30天内住院的可能性较小，这是由于临终关怀协作的排他性水平；以及(2)如果居民居住在与以下方面有专属关系的医院，则可能在生前30天内住院 临终关怀提供者，占临终关怀使用量。AIM-2旨在探索AIM-1中确定的关系是否在临终关怀提供者增长率不同的州之间存在差异。这项研究具有创新性，因为它是第一次研究NH-临终关怀协作的排他性与EOL住院之间的关系，它通过检查所有NH临终关怀居民而不仅仅是临终关怀参与者使用临终关怀的影响来扩展现有的研究。它还利用纵向数据和临终关怀提供者增长率的地理差异，将NH-临终关怀协作与EOL住院之间的估计关系中的潜在偏差降至最低。这项研究意义重大，因为它将增加我们对NH-临终关怀协作如何改善所有濒临死亡的NH居民的护理，特别是EOL住院治疗的理解。这些发现对于政策制定者评估临终关怀使用的成本和好处，以及NH提供者做出与临终关怀机构合作的明智决定都将是重要的。最终，减少EOL住院不仅将改善临终居民的生活质量，还将节省医疗保险成本。

DESCRIPTION (provided by applicant): Dying nursing home (NH) residents are frequently hospitalized within the last 30 days of their lives, resulting in worse health outcomes and high Medicare costs. While it has been shown that hospice use leads to lower hospitalization rates among hospice enrollees, it is unclear how the attributes of NH-hospice collaborations - specifically the volume of hospice use and exclusivity of the collaboration (i.e. whether a NH primarily collaborates with one versus two or more providers) - are associated with hospitalizations among all NH dying residents (NH-hospice collaborations may also benefit non-hospice residents through spill-over effects). The rapid growth of hospice providers in NH markets and substantial geographic variations in such growth provide us with an opportunity to study the relationship between changing attributes of NH-hospice collaborations and end-of-life (EOL) hospitalizations. The long-term goal is to understand the approaches that can be used to improve palliative care for dying residents and to reduce costs. The objective of this study is to understand how specific attributes of NH-hospice collaborations are associated with EOL hospitalizations in NH. The rationale is that this study will pave the way for further in-depth studies of the causal relationship between NH-hospice collaborations and EOL hospitalizations, and ultimately provide guidance for better hospice palliative care delivery to all dying NH residents. Using national data from 2000-2009, this study has two aims. Aim-1 is to examine the relationship between attributes of NH-hospice collaborations and EOL hospitalizations by testing the following 2 hypotheses among ALL NH decedents. (1) A resident is less likely to be hospitalized in the 30 days before death if residing in a NH with a higher volume of hospice use, accounting for the level of exclusivity of NH-hospice collaborations; and (2) A resident is likely o be hospitalized in the 30 days before death if residing in a NH with an exclusive relationship with a hospice provider, accounting for the volume of hospice use. Aim-2 is to explore whether the relationship identified in Aim-1 varies across states with different growth rates of hospice providers. This study is innovative because it is the first study to examine the relationship between exclusivity of NH-hospice collaborations and EOL hospitalizations, and it extends existing research by examining the effect of hospice use among all NH dying residents rather than only hospice enrollees. It also takes advantage of both longitudinal data and the geographic variations in the growth rates of hospice providers to minimize the potential bias in the estimated relationship between NH-hospice collaborations and EOL hospitalizations. This study is significant because it will add to our understanding of how NH-hospice collaborations can improve care, specifically EOL hospitalizations, for all dying NH residents. The findings will be important both for policymakers to evaluate the costs and benefits of hospice use, and for NH providers to make informed decisions about collaborating with hospices. Ultimately, reducing EOL hospitalizations will not only improve the quality of life for dying residents, but alo save Medicare costs.