ADRD: Greater Advanced Practice Clinician Involvement for End-of-Life Care Decreases Hospital Encounters

Patients with Alzheimer disease (AD) and related dementia (ADRD) who received more care from an advanced practice clinician (APC) at the end of life had lower hospitalization rates and higher hospice enrollment rates, according to authors of a study published in Alzheimer’s & Dementia.

The current study was designed to assess whether APCs have an effect on end-of-life care management in the setting of ADRD. Using a cross-sectional design, investigators evaluated Medicare claims and beneficiary data collected between 2016 and 2018. Data from the last 9 months of a decedent’s life were reviewed for hospitalization, hospice utilization, and APC claims; the last month of life was used to measure outcomes. The patients with ADRD were stratified into nursing home (n=322,461) and community (n=517,490) cohorts. Minimal APC involvement was defined as involvement in 0% to 10% of primary care visits, moderate APC involvement was defined as involvement in 11% to 50% of visits, and extensive APC involvement was defined as involvement in more than 50% of visits.

Of the study participants, 59.6% experienced minimal APC care, 21.2% experienced moderate care, and 19.2%, extensive. In the nursing home group, 34.6%, 25.3%, and 40.1% received minimal, moderate, and extensive APC care, respectively.

The mean (SD) age of study participants was 85.16 (8.06) years. A total of 56% were women, 87% were White, 58% were enrolled in hospice care, and 58% had a hospital visit in the final month of their life.

In a propensity score-weighted regression analysis of the nursing home cohort, compared with individuals who had minimal APC involvement, moderate APC involvement was associated with a 2.2% decrease in any hospital visit (P <.001) and a 1.3% increase in hospice enrollment (P <.001). Extensive APC involvement in the nursing home cohort was associated with a 3.0% decrease (P <.001) and 2.2% increase (P <.001) in any hospital visit and hospice enrollment, respectively.

Similarly, in the community cohort, compared with minimal APC involvement, moderate vs extensive APC involvement was associated with a 1.0% and 2.6% decrease in any hospital visit (both P <.001) and a 1.4% and 1.8% increase in hospice enrollment (both P <.001), respectively.

In both the nursing home and community cohorts, patients who had more than 1 APC visit per month at the end of their life and had more than 50% of their claims involving an APC had significantly lower hospital visit rates (P <.001) and greater hospice enrollment rates (P <.001) than patients with less APC involvement and fewer healthcare encounters.

Owing to the cross-sectional study design, no causal inferences can be drawn from these trends.

The study authors concluded, “We found that higher levels of APC involvement were associated with favorable end-of-life outcomes. There seems to be protective factors of APC involvement in the care of Medicare beneficiaries with ADRD in both nursing homes and the community.”