Evaluating A Hospital Intervention to Improve Care for Older Adults at the End of Life

Aim: 

Aim 1: Determine whether the receipt of aggressive care in the last 30 days of life among hospitalized older adults with cancer is associated with hospital Magnet recognition. Hypothesis: Patients in Magnet hospitals will be less likely to receive aggressive care, including chemotherapy in the last 14 days of life; more than 1 emergency room visit in the last 30 days of life; more than 1 hospitalization in the last 30 days of life; 1 or more ICU admissions in the last 30 days of life; in-hospital death; not admitted to hospice, or admitted to hospice for less than 3 days. Aim 2: Determine whether Black patients in Magnet hospitals receive less aggressive care in the last 30 days of life compared with Black patients in non-Magnet hospitals. Hypothesis: Black patients will be less likely than Whites to be cared for in Magnet hospitals. Black patients in Magnet hospitals will be less likely to receive aggressive care compared with Black patients in non-Magnet hospitals. Despite widespread efforts to improve patient-centered end of life care, older adults with cancer often receive poor quality care characterized by aggressive medical intervention which is often in conflict with their preferences for maximizing quality of life. We build on previous research, to generate new knowledge about the role of hospital nurses’ work environments in the provision of patient and family-centered care for terminally ill patients. If our hypotheses are confirmed, the findings from our study will inform efforts to improve care for seriously ill older adults who are hospitalized at the end of life.

Abstract: 

Over half of older adults with cancer are hospitalized during their last month of life, putting them at risk for aggressive medical interventions, which are associated with increased symptom burden, lower satisfaction, and poorer quality of life. Recent studies have shown that aggressive cancer care at the end of life, including chemotherapy, multiple hospitalizations, and intensive care unit admissions, are associated with lower hospice utilization and lower quality care. Despite widespread efforts to improve patient-centered end of life care and a robust evidence-base of clinical interventions, hospitalized older adults with cancer are experiencing increasingly more aggressive medical care in their last month of life. Moreover, widening racial disparities in end of life care are not entirely explained by differences in patient preferences. The proposed study brings a new perspective to the long-standing problem of achieving equitable and patient-centered care for older adults who are hospitalized at the end of life. We focus on the potential of hospital nurses, under the right circumstances, to render care consistent with what older adults say they want. Nurses, after all, are highly skilled at providing symptom management and comfort care, and are well-positioned to advocate for patients and families in the chaotic hospital environment. This observational study of hospitalized Medicare decedents with cancer investigates two hypotheses: (1) that older adults will be less likely to receive aggressive care in Magnet hospitals, which are designated by the American Nurses Credentialing Center as having exceptional nurse work environments characterized by collaborative interprofessional relationships with physicians, clinical autonomy in patient care, and manageable workloads; and (2) that Black patients in Magnet hospitals will be less likely to receive aggressive care compared with Black patients in non-Magnets. Using publically available data on hospital Magnet status, we anticipate a sample size of 396 hospitals in California and New Jersey, including 54 Magnet hospitals. Our anticipated patient sample size is approximately 35,000 Medicare beneficiaries with cancer who are hospitalized during the last 30 days of life. Patients will be identified using cancer registry data and linked to a hospital using a unique hospital identifier corresponding to the hospital the patient frequented most during the last month of life. Using inpatient, outpatient, and hospice claims data, we will construct validated measures of aggressive end of life care including receipt of chemotherapy in the last 14 days of life, no admission to hospice or admitted for less than 3 days, in-hospital death, or more than 1 emergency department visit, hospitalization, or ICU admission in the last 30 days of life. Our analytic approach applies hierarchical linear modeling in which we introduce patient and hospital variables sequentially to test our hypotheses. If our hypotheses are supported, findings from this study could translate into clinical interventions to improve the quality of end of life care and reduce disparities for older adults who find themselves in the hospital at the end of life.

Funded By: 
PARC
Award Dates: 
July 1, 2018 - June 30, 2019
PARC Grant Year: 
Year 25