Dying with dementia in Medicare Advantage, Accountable Care Organizations, or traditional Medicare.

Autor: Teno JM; Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland, Oregon, USA., Keohane LM; Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, USA., Mitchell SL; Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA., Meyers DJ; Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA., Bunker JN; Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland, Oregon, USA., Belanger E; Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA., Gozalo PL; Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA., Trivedi AN; Department of Health Services, Policy and Practice, Alpert Medical School of Brown University, Providence, Rhode Island, USA.
Jazyk: angličtina
Zdroj: Journal of the American Geriatrics Society [J Am Geriatr Soc] 2021 Oct; Vol. 69 (10), pp. 2802-2810. Date of Electronic Publication: 2021 May 14.
DOI: 10.1111/jgs.17225
Abstrakt: Background/objective: Medicare Advantage (MA) and Accountable Care Organizations (ACOs) operate under incentives to reduce burdensome and costly care at the end of life. We compared end-of-life care for persons with dementia who are in MA, ACOs, or traditional Medicare (TM).
Design, Setting, and Participants: Retrospective study of decedents with dementia enrolled in MA, attributed to an ACO, or in TM. Decedents had a nursing home stay between 91 and 180 days prior to death, two or more functional impairments, and mild to severe cognitive impairment.
Measurements: Hospitalization, invasive mechanical ventilation (IMV) use, and in-hospital death in the last 30 days of life reported in Medicare billing.
Results: Among 370,094 persons with dementia, 93,801 (25.4%) were in MA (mean age [SD], 86.9 [7.7], 67.6% female), 39,586 (10.7%) were ACO attributed (mean age [SD], 87.2 [7.6], 67.3% female), and 236,707 (63.9%) were in TM (mean age [SD], 87.0 [7.8], 67.6% female). The proportion hospitalized in the last 30 days of life was higher among TM enrollees (27.9%) and those ACO attributed (28.1%) than among MA enrollees (20.5%, p ≤ 0.001). After adjustment for socio-demographics, cognitive and functional impairments, comorbidities, and Hospital Referral Region, adjusted odds of hospitalization in the 30 days prior to death was 0.72 (95% confidence interval [CI] 0.70-0.74) among MA enrollees and 1.05 (95% CI 1.02-1.09) among those attributed to ACOs relative to TM enrollees. Relative to TM, the adjusted odds of death in the hospital were 0.78 (95% CI 0.75-0.81) among MA enrollees and 1.02 (95% CI 0.96-1.08) for ACO participants. Dementia decedents in MA had a lower likelihood of IMV use (adjusted odds ratio 0.80, 95% CI 0.75-0.85) compared to TM.
Conclusions: Among decedents with dementia, MA enrollees but not decedents in ACOs experienced less costly and potentially burdensome care compared with those with TM. Policy changes are needed for ACOs.
(© 2021 The American Geriatrics Society.)
Databáze: MEDLINE
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