Association of increasing use of mechanical ventilation among nursing home residents with advanced dementia and intensive care unit beds

Joan Teno, Pedro Gozalo, Nita Khandelwal, J. Randall Curtis, David Meltzer, Ruth Engelberg, Vincent Mor

Research output: Contribution to journalArticle

30 Citations (Scopus)

Abstract

IMPORTANCE Mechanical ventilation may be lifesaving, but in certain persons, such as those with advanced dementia, it may prolong patient suffering without a clear survival benefit. OBJECTIVE To describe the use and outcomes of mechanical ventilation and its association with the increasing numbers of intensive care unit (ICU) beds in the United States for patients with advanced dementia residing in a nursing home 120 days before that hospital admission. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study evaluated Medicare beneficiaries with advanced dementia hospitalized from January 1, 2000, to December 31, 2013, using the Minimum Data Set assessments linked with Medicare part A claims. A hospital fixed-effect, multivariable logistic regression model examined the effect of changes in ICU beds within individual hospitals and the likelihood of receiving mechanical ventilation, controlling for patients' demographic characteristics, function, and comorbidities. MAIN OUTCOMES AND MEASURES Mechanical ventilation. RESULTS From 2000 to 2013, a total of 635 008 hospitalizations of 380 060 eligible patients occurred (30.5%male and 69.5%female; mean [SD] age, 84.4 [7.4] years). Use of mechanical ventilation increased from 39 per 1000 hospitalizations in 2000 to 78 per 1000 hospitalizations in 2013 (P < .001, test of linear trend). As the number of ICU beds in a hospital increased over time, patients with advanced dementia were more likely to receive mechanical ventilation (ie, adjusted odds ratio per 10 ICU bed increase, 1.06; 95%CI, 1.05-1.07). In 2013, hospitals in the top decile in the number of ICU beds were reimbursed $9611.89 per hospitalization compared with $8050.24 per hospitalization in the lower decile (P < .001) without an improvement in 1-year mortality (65.2%vs 64.6%; P = 54). CONCLUSIONS AND RELEVANCE Among hospitalized nursing home residents with advanced dementia, we found an increase in the use of mechanical ventilation over time without substantial improvement in survival. This increase in the use of mechanical ventilation was associated with an increase in the number of ICU beds within a hospital.

Original languageEnglish (US)
Pages (from-to)1809-1816
Number of pages8
JournalJAMA Internal Medicine
Volume176
Issue number12
DOIs
StatePublished - Dec 1 2016
Externally publishedYes

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Nursing Homes
Artificial Respiration
Intensive Care Units
Dementia
Hospitalization
Medicare Part A
Logistic Models
Survival
Medicare
Comorbidity
Cohort Studies
Retrospective Studies
Odds Ratio
Demography
Mortality

ASJC Scopus subject areas

  • Internal Medicine

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Association of increasing use of mechanical ventilation among nursing home residents with advanced dementia and intensive care unit beds. / Teno, Joan; Gozalo, Pedro; Khandelwal, Nita; Curtis, J. Randall; Meltzer, David; Engelberg, Ruth; Mor, Vincent.

In: JAMA Internal Medicine, Vol. 176, No. 12, 01.12.2016, p. 1809-1816.

Research output: Contribution to journalArticle

Teno, Joan ; Gozalo, Pedro ; Khandelwal, Nita ; Curtis, J. Randall ; Meltzer, David ; Engelberg, Ruth ; Mor, Vincent. / Association of increasing use of mechanical ventilation among nursing home residents with advanced dementia and intensive care unit beds. In: JAMA Internal Medicine. 2016 ; Vol. 176, No. 12. pp. 1809-1816.
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abstract = "IMPORTANCE Mechanical ventilation may be lifesaving, but in certain persons, such as those with advanced dementia, it may prolong patient suffering without a clear survival benefit. OBJECTIVE To describe the use and outcomes of mechanical ventilation and its association with the increasing numbers of intensive care unit (ICU) beds in the United States for patients with advanced dementia residing in a nursing home 120 days before that hospital admission. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study evaluated Medicare beneficiaries with advanced dementia hospitalized from January 1, 2000, to December 31, 2013, using the Minimum Data Set assessments linked with Medicare part A claims. A hospital fixed-effect, multivariable logistic regression model examined the effect of changes in ICU beds within individual hospitals and the likelihood of receiving mechanical ventilation, controlling for patients' demographic characteristics, function, and comorbidities. MAIN OUTCOMES AND MEASURES Mechanical ventilation. RESULTS From 2000 to 2013, a total of 635 008 hospitalizations of 380 060 eligible patients occurred (30.5{\%}male and 69.5{\%}female; mean [SD] age, 84.4 [7.4] years). Use of mechanical ventilation increased from 39 per 1000 hospitalizations in 2000 to 78 per 1000 hospitalizations in 2013 (P < .001, test of linear trend). As the number of ICU beds in a hospital increased over time, patients with advanced dementia were more likely to receive mechanical ventilation (ie, adjusted odds ratio per 10 ICU bed increase, 1.06; 95{\%}CI, 1.05-1.07). In 2013, hospitals in the top decile in the number of ICU beds were reimbursed $9611.89 per hospitalization compared with $8050.24 per hospitalization in the lower decile (P < .001) without an improvement in 1-year mortality (65.2{\%}vs 64.6{\%}; P = 54). CONCLUSIONS AND RELEVANCE Among hospitalized nursing home residents with advanced dementia, we found an increase in the use of mechanical ventilation over time without substantial improvement in survival. This increase in the use of mechanical ventilation was associated with an increase in the number of ICU beds within a hospital.",
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