A comprehensive analysis of millions of Medicare records conducted by Rutgers Health has paved the way for enhancing end-of-life care by revealing that nearly all older Americans follow one of nine trajectories in their last three years of life. This critical insight is essential for identifying factors influencing different paths and designing interventions tailored to individual needs.
Olga Jarrín, the Hunterdon Professor of Nursing Research at Rutgers and corresponding author of the study, emphasises that understanding these trajectories is a crucial step in improving care experiences, reducing costs, and enhancing care quality.
The research team examined the final three years of clinical records from a randomly selected 10% of the 2 million Medicare beneficiaries who passed away in 2018. By analyzing personal care levels and the care settings, three major care clusters emerged—home, skilled home care, and institutional care. Each cluster revealed three distinct trajectories, providing valuable insights into the varied end-of-life experiences.
Approximately 59% of patients fell into the “home” cluster, indicating that they spent most of the their last three years at home, with support from friends and family for tasks they couldn’t manage independently. This group typically received minimal professional care until the last year of life.
The “skilled home care” cluster accounted for 27% of patients, who received assistance from nurses and other skilled professionals within their homes for most of the final three years.
The remaining 14% belonged to the “institutional care” cluster, spending most of the their last three years in hospitals or nursing homes, receiving essential care from paid professionals.
Using a group-based trajectory modeling approach, the researchers examined associations between care trajectories and various sociodemographic and health-related metrics. Patients in the skilled home care and institutional care clusters were more likely to be female, Black, enrolled in Medicaid, or dealing with dementia. The study also revealed regional variations, with Southern states showing a higher prevalence of extensive skilled home care use and Midwestern states more commonly opting for extensive institutional care.
Haiqun Lin, the lead author of the study and a professor of biostatistics, emphasized the importance of understanding these patterns for advance care planning. Recognizing the clinical and policy factors influencing where and when patients receive care is crucial for achieving the triple aim of improving care experiences, reducing care costs, and enhancing care quality.
This study is the first in a series planned by the researchers based on their analysis of Medicare data. Having identified the trajectories people follow in their last years of life, the team aims to uncover key factors directing individuals down each path and develop interventions to support individuals in sticking to the path of their preference.
While most people express a desire to stay at home with minimal professional help, Jarrín acknowledges that a significant minority prefers to avoid burdening family and friends and, as a result, seeks professional care. The goal of the research is not to force people toward a specific type of care but to assist them in planning for and receiving the care that aligns with their preferences.
In conclusion, the Rutgers Health analysis of Medicare records provides valuable insights into the diverse trajectories older Americans follow in their last three years of life. The identification of distinct care clusters and trajectories informs the development of targeted interventions, advancing the goals of personalized and effective end-of-life care. The research contributes to the ongoing effort to improve care experiences, reduce costs, and enhance care quality for individuals navigating their final years.
Journal Reference
Place of Care in the Last Three Years of Life for Medicare Beneficiaries, BMC Geriatrics (2024). DOI: 10.1186/s12877-023-04610-w.
