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Original Investigation
December 2016

Association of Increasing Use of Mechanical Ventilation Among Nursing Home Residents With Advanced Dementia and Intensive Care Unit Beds

Author Affiliations
  • 1Department of Gerontology and Geriatrics, University of Washington, Seattle
  • 2Cambia Palliative Care Center of Excellence, University of Washington Medicine, Seattle
  • 3Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
  • 4Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
  • 5Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle
  • 6Department of Medicine, University of Chicago, Chicago, Illinois
  • 7Providence Veterans Administration Hospital, Providence, Rhode Island
JAMA Intern Med. 2016;176(12):1809-1816. doi:10.1001/jamainternmed.2016.5964
Key Points

Question  Among hospitalized patients with advanced dementia, how is the use of mechanical ventilation associated with the increasing number of intensive care unit (ICU) beds?

Findings  In this cohort study, mechanical ventilation increased 2-fold without improved survival. Nursing home residents admitted to a hospital that increased their ICU beds by 10 had an increased risk for mechanical ventilation.

Meaning  Increasing rates of mechanical ventilation raise the need for multifaceted interventions to improve advance care planning in nursing homes, decision making in the hospital, and a national strategic plan regarding regional ICU bed growth.


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.