Annals of Long Term Care

FROM THE JOURNAL OF THE AMERICAN GERIATRICS SOCIETY

Skilled Care Requirements for Elderly Patients After Coronary Artery Bypass Grafting
Brahmajee K. Nallamothu, MD, MPH, Mary A. M. Rogers, PhD, MS, Sanjay Saint, MD, MPH, Laurence J. McMahon, Jr., MD, MPH, Brant E. Fries, PhD, Samuel R. Kaufman, MSc and Kenneth M. Langa, MD, PhD

Objectives: To examine the extent to which elderly individuals use various skilled care facilities after coronary artery bypass grafting (CABG).

Design: Retrospective cohort study.

Setting: State of Michigan from 1997 to 1998.

Participants: Residents aged 65 and older enrolled in Medicare who underwent CABG.

Measurements: Cumulative incidence of admission within 100 days of hospital discharge, relative risk (RR) of admission, readmission or extended stay at a skilled care facility, and length of stay in a skilled care facility.

Results: Fifty percent of patients aged 80 and older used a skilled care facility after CABG, with most requiring admission to a skilled nursing facility (SNF) or readmission to an acute-care hospital within 100 days after discharge. Patients aged 80 and older had a significantly higher risk of admission to a SNF (adjusted RR=3.3, 95% confidence interval (CI)=2.8–4.0) than did those aged 65 to 69, as did patients aged 75 to 79 (adjusted RR=2.2, 95% CI=1.8–2.6) and those aged 70 to 74 (adjusted RR=1.5, 95% CI=1.3–1.8). The length of time spent in skilled care facilities significantly increased with age (mean days=13.3 for aged 65–69, 16.9 for 70–74, 19.6 for 75–79, and 22.9 for 80 and older; P<.001).

Conclusion: Older patients are more likely to be admitted to a SNF, be readmitted to an acute-care hospital, and have longer institutional stays after CABG. When balancing the risks and benefits of CABG, physicians, patients, families, and policy-makers need to carefully consider the likelihood of follow-up institutional care in elderly patients. J Am Geriatr Soc 2005;53(7):1133-1137.

End-of-Life Care in Black and White: Race Matters for Medical Care of Dying Patients and their Families
Lisa C. Welch, PhD, Joan M. Teno, MD, MS, and Vincent Mor, PhD

Objectives: To compare the end-of-life medical care experienced by African-American and white decedents and their families.

Design: Cross-sectional, retrospective survey with weighted results based on a two-stage probability sampling design.

Setting: Hospitals, nursing homes, and home-based medical services across the United States.

Participants: Surrogates (N=1,447; primarily family members) for decedents from 22 states.

Measurements: Validated end-of-life care outcomes concerning symptom management, decision-making, informing and supporting families, individualized care, coordination, service utilization, and financial impact.

Results: Family members of African-American decedents were less likely than those of white decedents to rate the care received as excellent or very good (odds ratio (OR)=0.4). They were more likely to report absent (OR=2.4) or problematic (OR=1.9) physician communication, concerns with being informed (OR=2.5), and concerns with family support (OR=2.6). Family members of African Americans were less likely than those of whites to report that the decedent had treatment wishes (OR=0.3) or written advance care planning documents (OR=0.4). These differences persist when limiting the sample to respondents whose expectations for life-sustaining treatments matched treatments received. Family members of African-American decedents also were more likely to report financial hardship due to savings depletion (OR=2.1) or difficulty paying for care (OR=2.0) and that family/friends (OR=2.0) or home health workers (OR=1.9) provided home care.

Conclusion: This national study brings evidence that racial disparities persist into end-of-life care, particularly regarding communication and family needs.