Dying in U.S. Nursing Homes with Advanced Dementia: How Does Health Care Use Differ for Residents with, versus without, End-of-Life Medicare Skilled Nursing Facility Care?

Abstract Background: Because Medicare policy restricts simultaneous Medicare hospice and skilled nursing facility (SNF) care, we compared hospice use and sites of death for SNF/non-SNF residents with advanced dementia; and, for those with SNF, we evaluated how subsequent hospice use was associated with dying in a hospital. Methods: This study includes (non-health maintenance organization [HMO]) residents of U.S. nursing homes (NHs) who died in 2006 with advanced dementia (n=99,370). Sites of death, Medicare SNF, and hospice use were identified using linked resident assessment and Medicare enrollment and claims data. Advanced dementia was identified by a diagnosis of Alzheimer's disease or dementia on the Minimum Data Set (MDS) or a Medicare claim in the last year of life and severe to very severe cognitive impairment (5 or 6 on the MDS cognitive performance scale). For residents with SNF, we used multivariate logistic regression with generalized estimating equations to estimate the effect of subsequent ho...