Nursing home residents with advanced cognitive impairment who undergo multiple hospitalizations

"Multiple hospitalizations for complications from a terminal illness may be burdensome for elderly patients and reflect poor quality care," write Joan M. Teno, M.D., M.S., of the Warren Alpert School of Medicine of Brown University, Providence, R.I., and colleagues in the current JAMA issue, who conducted a study to examine whether the occurrence of multiple hospitalizations for the complications of infections or dehydration was associated with survival.

As reported in a Research Letter, the study population was identified using data from the national Minimum Data Set repository, which includes standardized assessments regularly completed by staff on all nursing home (NH) residents in the United States between January 2000 and December 2008. The researchers identified the first baseline assessment in which a resident had a Cognitive Performance Score of 4, 5, or 6 indicating moderate to very severe cognitive impairment. Residents were followed up for l year from the baseline assessment date (through 2009), and residents were identified who had 2 or more hospitalizations for the same type of the following diagnoses: pneumonia, urinary tract infection (UTI), septicemia, or dehydration or malnutrition.

Between 2000 and 2008, 1.3 million NH residents attained a Cognitive Performance Score of 4, 5, or 6 and survived at least 30 days after that assessment. Compared with overall survival (476 days), the adjusted survival was significantly lower for all of the burdensome transitions: pneumonia, 95 days; UTI, 146 days; dehydration or malnutrition, 111 days; and septicemia, 89 days.

"Future research is needed to understand whether these transitions are based on financial incentives, poor communication, or a lack of resources needed to diagnose and treat a NH resident," the authors write. "… the observed survival suggests that the first hospitalization with these diagnoses for NH residents with advanced cognitive impairment should result in reconsideration of the goals of care and the appropriateness of continued hospitalizations."