The Impact of Advanced Practice Clinicians on End of Life Outcomes for Older Adults with Dementia

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ABSTRACT Individuals with Alzheimer’s disease and related dementias (ADRD) often face hospitalizations and other burdensome interventions at end of life that could be avoided with better preemptive medical care – specifically, early recognition and treatment of acute illness, improved advance care planning and palliative care, and availability of resources to manage acute conditions in the outpatient setting. Nurse practitioners and physician assistants, collectively known as advanced practice clinicians (APCs), are playing an increasingly important role in the medical management of older adults in both nursing home and community settings, yet little is known about how these clinicians influence end of life outcomes for people with ADRD under traditional fee-for-service Medicare. Additionally, APC scope of practice is governed by state regulations which vary considerably and it is unknown how these regulations impact the provision of end of life care to people with ADRD, particularly those living in rural or medically underserved areas. The long-term goal of this research is to develop evidence that will inform workforce planning and policy efforts to provide high quality care to people with ADRD at end of life. Our central hypotheses are that APCs provide services to vulnerable sub-populations of people with ADRD who may otherwise have poor access to quality end of life care; and that the involvement of APCs in care reduces the likelihood of being exposed to burdensome interventions at end of life. To test these hypotheses, we propose a cross-sectional study using 2015-2018 Medicare claims and administrative data with the following specific aims: (1) To describe population and state regulatory characteristics associated with people with ADRD receiving care from APCs at end of life; (2) To evaluate whether APC care is associated with acute care utilization in the last month of life, death in a hospital, hospice utilization, and feeding tube placement for people with ADRD; and (3) To evaluate whether the effects of APC care on end of life outcomes vary across states with different scope of practice regulations. This will be the first study to examine the impact of APCs on end of life outcomes for individuals with ADRD, or for any population of Medicare beneficiaries. Findings from this study will inform staffing composition for nursing homes, physician practices, and other healthcare organizations that care for people with ADRD; provide guidance to state policymakers who design APC scope of practice regulations; and inform workforce planning, training, and recruitment efforts for schools and healthcare organizations.