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Zhanlian Feng, PhD; Michael Lepore, PhD; Melissa A. Clark, PhD; et al.
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Arch Intern Med. 2011;171(9):806-813. doi:10.1001/archinternmed.2010.492
BackgroundWhile demographic shifts project an increased need for long-term care for an aging population, hundreds of nursing homes close each year. We examine whether nursing home closures are geographically concentrated and related to local community characteristics such as the racial and ethnic population mix and poverty.MethodsNational Online Survey Certification and Reporting data were used to document cumulative nursing facility closures over a decade, 1999 through 2008. Census 2000 zip code level demographics and poverty rates were matched to study facilities. The weighted Gini coefficient was used to measure geographic concentration of closures, and geographic information system maps to illustrate spatial clustering patterns of closures. Changes in bed supply due to closures were examined at various geographic levels.ResultsBetween 1999 and 2008, a national total of 1776 freestanding nursing homes closed (11%), compared with 1126 closures of hospital-based facilities (nearly 50%). Combined, there was a net loss of over 5% of beds. The relative risk of closure was significantly higher in zip code areas with a higher proportion of blacks or Hispanics or a higher poverty rate. The weighted Gini coefficient for closures was 0.55 across all metropolitan statistical areas and 0.71 across zip codes. Closures tended to be spatially clustered in minority-concentrated zip codes around the urban core, often in pockets of concentrated poverty.ConclusionsNursing home closures are geographically concentrated in minority and poor communities. Since nursing home use among the minority elderly population is growing while it is declining among whites, these findings suggest that disparities in access will increase.
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Editorial
There's No Place Like Home
Mitchell H. Katz, MD
ONLINE FIRST
Niteesh K. Choudhry, MD, PhD; Michael A. Fischer, MD, MS; Jerry Avorn, MD; et al.
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Arch Intern Med. 2011;171(9):814-822. doi:10.1001/archinternmed.2010.495
BackgroundPatients with chronic disease often take many medications multiple times per day. Such regimen complexity is associated with medication nonadherence. Other factors, including the number of pharmacy visits patients make to pick up their prescriptions, may also undermine adherence. Our objective was to estimate the extent of prescribing and filling complexity in patients prescribed a cardiovascular medication and to evaluate its association with adherence.MethodsThe study population comprised individuals prescribed a statin (n = 1 827 395) or an angiotensin- converting enzyme inhibitor or renin angiotensin receptor blocker (ACEI/ARB) (n = 1 480 304) between June 1, 2006, and May 30, 2007. We estimated complexity by measuring the number of medications, prescribers, pharmacies, pharmacy visits, and refill consolidation (a measure of the number of visits per fill) during the 3 months from the first prescription. The number of daily doses was also measured in ACEI/ARB users. After this period, adherence was evaluated over the subsequent year. The relationship between complexity and adherence was assessed with multivariable linear regression.ResultsThe statin cohort had a mean age of 63 years and were 49% male. On average, during the 3-month complexity assessment period, statin users filled 11.4 prescriptions for 6.3 different medications, had prescriptions written by 2 prescribers, and made 5.0 visits to the pharmacy. Results for ACEI/ARB users were similar. Greater prescribing and filling complexity was associated with lower levels of adherence. In adjusted models, patients with the least refill consolidation had adherence rates that were 8% lower over the subsequent year than patients with the greatest refill consolidation.ConclusionMedication use and prescription filling for patients with cardiovascular disease is complex, and strategies to reduce this complexity may help improve medication adherence.
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Keith S. Goldfeld, MPA, MS; David G. Stevenson, PhD; Mary Beth Hamel, MD, MPH; et al.
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Arch Intern Med. 2011;171(9):824-830. doi:10.1001/archinternmed.2010.478
BackgroundNursing home residents with advanced dementia commonly experience burdensome and costly interventions (eg, tube feeding) that may be of limited clinical benefit. To our knowledge, Medicare expenditures have not been extensively described in this population.MethodsNursing home residents with advanced dementia in 22 facilities (N = 323) were followed up for 18 months. Clinical and health services use data were collected every 90 days. Medicare expenditures were described. Multivariate analysis was used to identify factors associated with total 90-day expenditures for (1) all Medicare services and (2) all Medicare services excluding hospice.ResultsOver an18-month period, total mean Medicare expenditures were $2303 per 90 days but were highly skewed; expenditures were less than $500 for 77.1% of the 90-day assessment periods and more than $12 000 for 5.5% of these periods. The largest proportion of Medicare expenditures were for hospitalizations (30.2%) and hospice (45.6%). Among decedents (n = 177), mean Medicare expenditures increased by 65% in each of the last 4 quarters before death owing to an increase in both acute care and hospice. After multivariable adjustment, not living in a special care dementia unit was a modifiable factor associated with higher total expenditures for all Medicare services. Lack of a do-not-hospitalize order, tube feeding, and not living in a special care unit were associated with higher nonhospice Medicare expenditures.ConclusionsMedicare expenditures among nursing home residents with advanced dementia vary substantially. Hospitalizations and hospice account for most spending. Strategies that promote high-quality palliative care may shift expenditures away from aggressive treatments for these patients at the end of life.
Less Is More
Renda Soylemez Wiener, MD, MPH; Lisa M. Schwartz, MD, MS; Steven Woloshin, MD, MS
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Arch Intern Med. 2011;171(9):831-837. doi:10.1001/archinternmed.2011.178
Health Care Reform
Jeffrey A. Tabas, MD; Christy Boscardin, PhD; Donna M. Jacobsen, BS; et al.
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Arch Intern Med. 2011;171(9):840-846. doi:10.1001/archinternmed.2011.179