Intensive care utilization among nursing home residents with advanced cognitive and severe functional impairment.

Abstract

Dementia is a progressive terminal illness which requires decisions around aggressiveness of care. The study objective was to examine the rate of intensive care unit (ICU) utilization and its regional variation among persons with both advanced cognitive and severe functional impairment. We utilized the Minimum Data Set (MDS) to identify a cohort of decedents between 2000 and 2007 who (1) were in a nursing home (NH) 120 days prior to death and (2) had an MDS assessment indicating advanced cognitive and functional impairment as identified by cognitive performance scale (CPS) ≥5 and total dependence or extensive assistance in seven activities of daily living (ADLs). ICU utilization in the last 30 days of life was determined from Medicare claims files. A multivariate logistic regression model examined the likelihood of ICU admission in 2007 versus 2000 adjusting for sociodemographics, orders to limit life sustaining treatment, and health status. Among 474,829 Medicare NH residents with advanced cognitive impairment followed during 2000-2007, we observed an increase in ICU utilization from 6.1% in 2000 to 9.5% in 2007. After adjustment for sociodemographic characteristics, orders to limit life sustaining treatment, and measures of health status, the likelihood of a resident being admitted to an ICU was higher in 2007 compared to 2000 (adjusted odds ratio [OR] 1.71, 95% CI 1.60-1.81). Additionally, substantial regional variation was noted in ICU utilization, from 0.82% in Montana to 22% in the District of Columbia. Even among patients with advanced cognitive and functional impairment, ICU utilization in the last 30 days increased and varied by geographic region.