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Ten-year trends in end-of-life hospitalizations of nursing home residents in Germany, 2006–2015
Journal Pre-proof Ten-year trends in end-of-life hospitalizations of nursing home residents in Germany, 2006-2015 Falk Hoffmann, Katharina Allers
PII:
S0378-5122(19)30842-4
DOI:
https://doi.org/10.1016/j.maturitas.2020.02.006
Reference:
MAT 7299
To appear in:
Maturitas
Received Date:
21 September 2019
Revised Date:
3 February 2020
Accepted Date:
18 February 2020
Please cite this article as: Hoffmann F, Allers K, Ten-year trends in end-of-life hospitalizations of nursing home residents in Germany, 2006-2015, Maturitas (2020), doi: https://doi.org/10.1016/j.maturitas.2020.02.006
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier.
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Ten-year trends in end-of-life hospitalizations of nursing home residents in Germany, 2006-2015 Running title: End-of-life hospitalizations of nursing home residents Falk Hoffmann1, Katharina Allers1 1
Carl von Ossietzky University Oldenburg, Department of Health Services Research, Oldenburg, Germany Corresponding author: Prof. Dr. Falk Hoffmann, MPH
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Carl von Ossietzky University Oldenburg Department of Health Services Research Ammerländer Heerstr. 140 D- 26129 Oldenburg, Germany Phone: +49 441/ 798- 2880
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E-mail: [email protected]
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Fax: +49 441/ 798- 5824
Highlights
End-of-life hospitalizations of nursing home residents are common in Germany.
We found a small decrease over recent years in the proportion of in-hospital deaths and no significant differences in hospitalization rates during the last 7, 14 and 30 days of life over a 10-year period.
The length of terminal hospitalizations decreased over time.
More studies should examine longitudinal trends.
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Abstract
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Objectives: We investigated trends in end-of-life hospitalizations among nursing home residents (NHR) over 10 years and looked at differences between age groups and sexes as well as the length of terminal hospital stays. Study design: Retrospective cohort study based on health insurance claims data of the AOK Bremen/Bremerhaven. All NHR aged 65 years or more who died between 2006 and 2015 were included.
2 Main outcome measures: We assessed the proportions of decedents who were in hospital on the day of death and during the last 3, 7, 14 and 30 days of life, stratified by two-year periods. Multiple logistic regressions were conducted to study changes over time, adjusting for covariates. Results: A total of 10,781 decedents were included (mean age 86.1 years, 72.1% females). Overall, 29.2% died in hospital, with a slight decrease from 30.3% in 20062007 to 28.3% in 2014-2015 (OR 0.86; 95% CI 0.75-0.98). Of the 3,150 terminal
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hospitalizations, 35.5% lasted up to 3 days and the mean length of stay decreased from 9.0 (2006-2007) to 7.5 days (2014-2015). When looking at the last 7, 14 and 30 days of life, no changes over time were found. Male sex and younger age were
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associated with a higher chance of end-of-life hospitalization in all analyses.
Conclusions: End-of-life hospitalizations of NHR are common in Germany. There has
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been a small decrease during recent years in the proportion of in-hospital deaths, but
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not of hospitalizations during the last 7, 14 and 30 days of life. This might be explained
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by shorter durations of hospital stays.
Keywords: Nursing homes, health services research, end-of-life care, long-term care,
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hospital use
1. Introduction During the last weeks of life, hospitalization rates of nursing home residents (NHR) increase substantially [1,2] and the proportion of in-hospital deaths ranges between 5.9% and 77.1% with large variations between countries [3]. Generally, it is critically discussed
whether
benefits
of
hospitalizations
outweigh
potential
negative
3 consequences for NHR [4,5]. This is especially the case for end-of-life hospitalizations, as residents dying soon after admission may not benefit from hospitalization [5,6]. As palliative approaches and advance directives are more common during recent years in nursing homes [7,8], one might suggest that there are also changes in endof-life hospitalizations of residents. However, only very few studies were conducted regarding this question. In a recent and comprehensive systematic review we only
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found 4 studies assessing trends over time [3]. All these data come from the United States (US) analyzing trends over 5, 9 or 10 years up to 2009 [9–12]. These studies assessed different periods before death and in two of them the proportion of NHR with
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end-of-life hospitalizations remained virtually unchanged [10,11], whereas one study found that the likelihood of in-hospital death even increased in a multivariable analysis
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[9]. Another study also reported an increase in hospitalizations during the last month of life from 24.8% in 2000 to 33.3% in 2009 [12]. Moreover, few studies have assessed
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the duration of terminal hospital stays, but these have reported a high proportion of
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people who died within the first three days of admission [13]. Taking together, the few studies assessing trends over time in end-of-life hospitalizations of NHRs showed mixed findings. No studies with data after 2009,
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assessing several different periods before death or from countries other than the US
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are available. For Germany, an indirect comparison of two studies suggest no difference in the proportion of in-hospital deaths of NHR from 2000-2001 (28.9%) [14] to 2010-2014 (29.5%) [1]. However, first of all, these studies used data of different health insurance funds. It is known that there are differences in morbidity and health services use including hospitalizations between members of different funds [15,16]. Furthermore, one of these studies included a regional sample and evidence from the
4 US and from France showed substantial regional variations of in-hospital deaths among NHR [9,17]. Therefore, the primary objective of this study was to investigate trends of end-of-life hospitalizations of NHR in Germany over 10 years using one and the same database. Our secondary objective was to study differences between age groups and sexes as well as the length of terminal hospital stays. All analyses were conducted for different periods within the last month of life.
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2. Methods
This retrospective cohort study is part of the large publicly funded project ‘HOMERN’ (Hospitalization and emergency department visits of nursing home residents) which
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2.1 Database, study population and outcome
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aims to explore health care of NHR with a focus on hospital transfers.
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We used administrative data of the AOK Bremen/Bremerhaven. With about 0.7 million inhabitants Bremen is the smallest of the 16 German federal states and the AOK
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Bremen/Bremerhaven insures about one third of this population. The study population included all NHR insured by the AOK Bremen/Bremerhaven that
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died between January 1, 2006, and December 31, 2015 and being aged 65+ years at death. No further inclusion or exclusion criteria were applied.
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Data on hospitalizations and on long-term care (‘‘Gesetzliche Pflegeversicherung’’) were available. Data on long-term care included information on nursing home placement and on levels of care dependency. These levels of care dependency range from care level I (considerable need of care) to care level III (most heavily care dependent) and are assigned by an independent authority. Care levels were used as an indicator of physical disabilities, which was also done in previous studies [18,19].
5 We assessed care levels at the day of death. Further information on the German longterm care as well as the health care system in total are available in Busse and Blümel [20]. Our outcome of interest was the proportion of decedents being in hospital at least once during the following end-of-life periods: the day of death (in-hospital death) as well as the last 3, 7, 14 and 30 days of life. Year of death, as our main independent variable, was divided in two-year periods
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(2006-2007, 2008-2009, 2010-2011, 2012-2013 and 2014-2015). 2.2 Statistical analysis
First, we compared baseline characteristics by year of death. Second, we calculated
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proportions with at least one hospitalization during the 5 end-of-life periods by year of
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death and estimated 95% confidence intervals (95% CIs) with the exact (ClopperPearson) method. Third, we fitted separate multiple logistic regression models for each
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of the 5 end-of-life periods to estimate odds ratios (OR) with 95% CI adjusting for covariates. Besides year of death (5 categories), we included sex (2 categories), age
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at the time of death (65-74, 75-84, 85-94 and 95+ years) and level of care dependency at the time of death (3 categories) in these multiple adjusted models. Fourth, we
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analysed durations of the hospitalization by year of death. All p-values less than 0.05 and non-overlapping 95% CI were considered statistically
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significant. Analyses were conducted with SAS for Windows version 9.4 (SAS Institute Inc, Cary, North Carolina). This study received a waiver from the medical ethics committee of the Carl von Ossietzky University of Oldenburg (2017-054).
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3. Results 3.1 Baseline characteristics A total of 10,781 NHR died between 2006 and 2015. They were on average 86.1 (SD: 7.9) years old, and about three quarter were female (72.1%). Most had care level II at the day of death (42.4%). The number of deaths ranged between 2,087 and 2,256 for the 5 two-year periods
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(Table 1). Mean age did not change through the years, but the proportion of males increased from 25.9% to 29.1% as did the proportion with low need of care (none/ levels I) from 16.6% to 23.1% (2006-2007 to 2014-2015).
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3.2 Hospitalizations at the end of life
Overall, the proportion of in-hospital deaths was 29.2% (Table 2). This proportion
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decreased slightly over time from 30.3% to 28.3% (2006-2007 to 2014-2015). As
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shown in Table 3, this is also supported by the multivariable analyses adjusting for covariates (OR: 0.86; 95% CI: 0.75-0.98).
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During the last 3, 7 and 14 days of life the proportions of NHR with at least one hospitalization were 31.6%, 35.7% and 41.2%, respectively (Table 2). A significant
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decrease over the years 2006-2007 to 2014-2015 was only found for the last 3 days of life (OR: 0.85; 95% CI: 0.74-0.97) and in none of the further analysed periods (Table
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3).
The proportion of NHR with at least one hospitalization during the last 30 days of life was 48.6% (Table 2). This proportion remained unchanged over time with 48.6% and 48.5% (2006-2007 to 2014-2015) and no significant association was found when adjusting for covariates, too (OR: 0.94; 95% CI: 0.83-1.06).
7 3.3 Differences in end-of-life hospitalization between age and sex There were large differences for age groups as well as for care levels. Overall, the proportion of in-hospital deaths decreases slightly from 37.9% in persons aged 65-74 years to 35.2% in persons aged 75-84 years and declines thereafter to 28.1% and 15.0% in those aged 85-94 and 95+ years. For care levels, a linear decrease of residents dying in a hospital was found from 43.4% (none/ level I) to 31.9% (level II) and 18.4% (level III). Males died more often in a hospital than women (34.0% vs.
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27.4%). These patterns for age groups, care levels and sex were found for all two-year periods, as shown in Table A1.
The same patterns as for in-hospital death were also found for hospitalizations during
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the last 3, 7, 14 and 30 days of life (Tables 2, A2-5). A total of 66.3% of residents with a low care level (none/ level I) were hospitalized at least once during the last 30 days
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of life, 52.2% with level II and 34.8% with level III (Table 2). This proportion was 59.6%
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and 56.1% in persons aged 65-74 and 75-84 years, respectively, and declines thereafter to 47.5% and 29.8% in NHR aged 85-94 and 95+ years. Differences
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between sexes were found (males: 57.0% and females: 45.4%). Again, these patterns were consistent for all two-year periods analysed.
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The multivariable analyses confirm these findings described above (Table 3). 3.4 Duration of terminal hospitalization
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The 3,150 terminal hospitalizations lasted on average 7.9 days (SD: 8.5) with a substantial decrease over time from 9.0 days (SD: 9.6) in 2006-2007 to 7.5 days (SD: 7.9) in 2014-2015. This decline was not linear, as the mean was 9.0 and 8.2 days up to 2009 and ranged between 7.3-7.5 days for the 3 two-year periods thereafter.
8 Overall, length of stay was 1 day in 11.0% of these hospitalizations (e.g. these patients died on the day of admission) and up to 3 days in 35.5% of decedents dying in hospital. For both measures there was no clear pattern as the length of stay of 1 day and up to 3 days ranged between 9.1-12.3% (with 10.8% in 2006-2007 and 11.0% in 2014-2015) and 30.7-39.7% (with 30.7% in 2006-2007 and 35.9% in 2014-2015) during the observation periods, respectively.
4. Discussion
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This is the first study assessing trends in end-of-life hospitalizations of NHR from another country than the US and the first analysing data up to 2015. Including more than 10,000 decedent NHR, we found that only in-hospital deaths decreased slightly
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during the observed period. No significant differences for hospitalization during the last 7, 14 and 30 days could be observed. Almost half of all deceased residents were in
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hospital during the last month of life. We found noticeable differences between sexes
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with male NHR having a higher chance of end-of-life hospitalizations in all assessed periods. Younger age and a lower level of care were associated with an increased
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likelihood of end-of-life hospitalizations. The length of terminal hospitalizations decreased over time and over one third of hospitalized residents died within three days
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after admission.
4.1 Comparison with other studies and interpretation
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It is evident that terminal hospitalizations are often burdensome for residents and their relatives and often result in adverse consequences [5,21]. However, with almost half of decedent NHR hospitalized in the last month of life and 30% dying in hospital, a high proportion of German residents is been transferred to hospital shortly before death. Overall, the hospitalization rates found in our study are higher compared to the median of 22.6% of in-hospital death and 33.2% of hospitalization during the last month of life
9 found in our recent systematic review that included all published studies worldwide with most being from the US [3]. Reasons for these differences might be explained by multiple factors, for example, resources available in the nursing home, availability of physicians or differences in qualifications of nurses or interprofessional communication between care providers [22]. Additionally, previous research showed that advance care planning and advance directives as do-not-hospitalize orders lead to a reduction of end-of-life hospitalizations [23–25]. Though advance care planning and palliative care
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approaches have become more common over the last years, in Germany, they are still rare [26–28].
No major differences in end-of-life hospitalizations could be observed in a period of ten
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years. Although the proportion dying in hospital decreased from 30.3% to 28.3% with a statistically significant difference when adjusting for covariates in the multivariable
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logistic regression, we found no significant difference for hospitalizations during the last month or weeks of life. This might be explained by decreasing lengths of hospital
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stay. Our findings are consistent with two prior studies from the US that found inhospital deaths and end-of-life hospitalizations remaining virtually unchanged over 5
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year and 9 year periods [10,11]. One study from the US even found increasing odds of NHR dying in hospitals over a five year period [9] and one study found an increased
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proportion of hospitalizations during the last month of life over a period of ten years
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[12]. Overall, there seem to be no decline in end-of-life hospitalizations in NHR. However, despite the importance of this topic there is little research conducted on longitudinal trends [3]. Again, we found noticeable differences between sexes with males having a higher chance of end-of-life hospitalizations compared to females in quite all assessed periods. This is well in line with the literature on overall hospitalizations of nursing home
10 residents, as our systematic review shows [29]. However, reasons for this are still unclear. A Canadian study hypothesized that the sex differences in end-of-life burdensome interventions are associated with sociocultural factors. Some possible explanations discussed by the authors are that women take more often part in advance care planning and discuss their preferences and wishes more often with their relatives, and are less afraid of death. Moreover, men might be more likely to have a wife who advocates for their care leading to a more aggressive treatments [30].
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Further, younger age and a lower level of care were associated with an increased likelihood of being in hospital during the last month of life and dying in hospital. These patterns were found in all years and the findings are similar to those from other studies
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[31–33]. This might indicate less aggressive end-of-life treatment in older and more care dependent residents.
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The length of terminal hospitalizations decreased over the years with an average
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length of hospital stay of 7.9 days (2006-2007: 9.0 days to 2014-2015: 7.5 days). To our knowledge this is the first study analyzing time trends concerning length of stay of
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terminal hospitalizations. In our recent systematic review, we only found four studies assessing the time spent in hospital before death at all [3] and none of them analyzed trends. More than one third of residents included in our study died within three days of
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admission with no clear pattern over time. This result is in line with an earlier study
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from Germany [14]. With regard to prior research which defined hospitalizations within three days likely to be manageable in the nursing home [34] and potentially burdensome [35], the proportion of 35.5% seems to be quite high. Interestingly, in a recent survey among general practitioners within the HOMERN project, 71.1% also agreed that NHR are treated in hospital too often at the end of life [36]. This underlines the need for improvement. A higher nurse staffing as well as better
11 training in palliative care for nurses as well as general practitioners were seen as important measures to improve end-of-life care among nursing home residents among respondents of this survey [36]. 4.2 Strengths and limitations The main strengths of this study were the large sample size of more than 10,000 decedents and the opportunity to assess trends over a 10 years period using one and the same database. We had access to administrative data and were able to study end-
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of-life hospitalizations without the typical shortcomings of field studies like nonresponse or recall bias.
Several limitations have to be considered as well. First, no facility characteristics could
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be analysed, which have been found to influence the decision to hospitalize [17,22]. In
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a recent study conducted in 21 German nursing homes, we also found variations in the proportion of residents being hospitalized at least once during the last 12 months
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between 20-74% [37]. However, facility characteristics including data on which residents come from which nursing home are generally not available in German health
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insurance claims data. Second, we did not have access to further clinical characteristics of residents, e.g. whether they had advance directives or how there
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cognitive or overall health status were. However, data on care levels at death were available, which is an indicator of physical disabilities [18,19]. Further, we also had no
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information about causes of death. Finally, we used data of just one regional health insurance fund. Compared to other funds, the AOK insures a lower educated population with a generally high burden of chronic diseases including high hospitalization rates [15,16].
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5. Conclusions In Germany the proportion of NHR being hospitalized shortly before death is high with no substantial change over a ten year period. Taken the available evidence together, there seem to be no decline in end-of-life hospitalizations of NHR in the US as well as in Germany during recent years. But overall, there is little research on trends over time and none from other than these two countries. More future studies should examine longitudinal trends, especially as a more widely implementation of advance care
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planning or palliative approaches should change the quality of end-of-life care and decrease burdensome hospitalizations shortly before death.
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Contributors
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Falk Hoffmann conceptualized the study, conducted the analyses and drafted the
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manuscript.
Katharina Allers conceptualized the study and conducted the analyses.
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the final version.
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Both authors interpreted the data, critically revised the manuscript, read and approved
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Conflict of interest
The authors declare that they have no conflict of interest.
Funding The project on which this publication is based was funded by the Innovation Committee at the Federal Joint Committee (Innovationsausschuss beim Gemeinsamen
13 Bundesausschuss; FKZ: 01VSF16055). We thank the AOK Bremen/Bremerhaven for providing the data.
Ethical approval This study received a waiver from the medical ethics committee of the Carl von
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Ossietzky University of Oldenburg (2017-054).
Provenance and peer review
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This article has undergone peer review.
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Research data (data sharing and collaboration)
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19 2014-2015 (n=2,087) 86.1±7.7
Total (n=10,781) 86.1±7.9
9.3% 27.9% 51.8% 11.0%
8.1% 31.0% 48.9% 12.1%
9.3% 28.9% 47.8% 14.0%
28.0% 72.0%
29.1% 70.9%
27.9% 72.1%
21.6% 41.1% 37.2%
23.1% 39.1% 37.9%
20.5% 42.4% 37.1%
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2012-2013 (n=2,178) 86.1±7.7
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Table 1. Baseline characteristics of decedents, by year of death 2006-2007 2008-2009 2010-2011 (n=2,109) (n=2,256) (n=2,151) Mean age at death±SD 86.3±8.1 86.0±8.0 86.2±7.9 Age groups 65-74 yrs. 10.1% 9.8% 8.9% 75-84 yrs. 26.8% 28.9% 30.2% 85-94 yrs. 47.1% 45.5% 45.7% 95+ yrs. 16.0% 15.8% 15.2% Sex Male 25.9% 28.0% 28.8% Female 74.1% 72.0% 71.2% Level of care at death None/Level I 16.6% 19.0% 22.0% Level II 46.8% 43.8% 41.2% Level III 36.6% 37.1% 36.8%
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Table 2. Proportion of nursing home residents with at least one end-of-life hospitalization (with 95% CI), by periods before death Day of death Last 3 days Last 7 days Last 14 days (n=10,781) (n=10,781) (n=10,781) (n=10,781) Year of death 2006-2007 30.3% (28.3-32.3%) 32.7% (30.7-34.8%) 36.5% (34.4-38.6%) 42.2% (40.0-44.3%) 2008-2009 30.2% (28.3-32.2%) 32.0% (30.1-34.0%) 36.0% (34.1-38.1%) 41.0% (39.0-43.1%) 2010-2011 29.8% (27.8-31.7%) 32.1% (30.2-34.1%) 36.1% (34.1-38.2%) 41.6% (39.5-43.7%) 2012-2013 27.5% (25.6-29.4%) 30.3% (28.3-32.3%) 34.3% (32.3-36-3%) 40.9% (38.8-43.0%) 2014-2015 28.3% (26.4-30.3%) 30.6% (28.6-32.6%) 35.4% (33.3-37.5%) 40.6% (38.5-42.8%) Age groups 65-74 yrs. 37.9% (34.9-41.0%) 40.2% (37.1-43.3%) 45.2% (42.1-48.3%) 51.1% (48.0-54.2%) 75-84 yrs. 35.2% (33.5-36.9%) 38.1% (36.4-39.8%) 42.7% (40.9-44.4%) 48.1% (46.3-49.8%) 85-94 yrs. 28.1% (26.9-29.4%) 30.3% (29.1-31.6%) 34.4% (33.1-35.7%) 40.2% (38.9-41.6%) 95+ yrs. 15.0% (13.2-16.9%) 16.5% (14.7-18.5%) 19.2% (17.2-21.3%) 24.1% (22.0-26.4%) Sex Male 34.0% (32.3-35.7%) 37.0% (35.3-38.8%) 42.2% (40.4-44.0%) 48.4% (46.6-50.2%) Female 27.4% (26.4-28.4%) 29.4% (28.4-30.5%) 33.1% (32.1-34.2%) 38.5% (37.4-39.6%) Level of care at death None/Level I 43.4% (41.3-45.5%) 47.1% (45.0-49.2%) 52.2% (50.1-54.3%) 58.5% (56.4-60.5%) Level II 31.9% (30.5-33.3%) 34.2% (32.8-35.6%) 38.6% (37.2-40.0%) 44.8% (43.4-46.3%) Level III 18.4% (17.2-19.6%) 19.9% (18.7-21.2%) 23.2% (21.9-24.6%) 27.7% (26.3-29.1%) Total 29.2% (28.4-30.1%) 31.6% (30.7-32.4%) 35.7% (34.8-36.6%) 41.2% (40.3-42.2%)
Last 30 days (n=10,781) 48.6% (46.4-50.8%) 48.4% (46.3-50.4%) 49.3% (47.2-51.5%) 48.3% (46.2-50.4%) 48.5% (46.4-50.7%) 59.6% (56.5-62.7%) 56.1% (54.3-57.8%) 47.5% (46.1-48.9%) 29.8% (27.5-32.2%) 57.0% (55.2-58.8%) 45.4% (44.3-46.5%) 66.3% (64.3-68.3%) 52.2% (50.7-53.7%) 34.8% (33.3-36.3%) 48.6% (47.7-49.6%)
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Table 3. Multivariable logistic regression for factors associated with end-of-life hospitalizations of nursing home residents, by periods before death Day of death Last 3 days Last 7 days Last 14 days Last 30 days (n=10,781) (n=10,781) (n=10,781) (n=10,781) (n=10,781) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Year of death 2006-2007 1 1 1 1 1 2008-2009 0.98 (0.86-1.12) 0.95 (0.83-1.08) 0.96 (0.85-1.09) 0.93 (0.82-1.06) 0.97 (0.86-1.10) 2010-2011 0.94 (0.82-1.08) 0.93 (0.82-1.06) 0.94 (0.83-1.07) 0.94 (0.82-1.06) 0.99 (0.87-1.12) 2012-2013 0.83 (0.72-0.95) 0.84 (0.73-0.96) 0.85 (0.75-0.97) 0.89 (0.79-1.02) 0.93 (0.82-1.06) 2014-2015 0.86 (0.75-0.98) 0.85 (0.74-0.97) 0.89 (0.78-1.02) 0.88 (0.77-1.00) 0.94 (0.83-1.06) Age groups 65-74 yrs. 3.00 (2.46-3.67) 2.89 (2.37-3.51) 2.91 (2.41-3.51) 2.72 (2.27-3.26) 2.81 (2.35-3.36) 75-84 yrs. 2.78 (2.36-3.27) 2.78 (2.37-3.26) 2.77 (2.38-3.23) 2.56 (2.22-2.95) 2.61 (2.28-2.99) 85-94 yrs. 2.05 (1.75-2.40) 2.02 (1.74-2.35) 2.02 (1.75-2.33) 1.93 (1.69-2.20) 1.93 (1.70-2.19) 95+ yrs. 1 1 1 1 1 Sex Male 1.09 (0.99-1.20) 1.13 (1.02-1.24) 1.18 (1.07-1.29) 1.21 (1.10-1.32) 1.28 (1.17-1.40) Female 1 1 1 1 1 Level of care at death None/Level I 3.19 (2.84-3.59) 3.36 (2.99-3.77) 3.38 (3.02-3.78) 3.44 (3.08-3.84) 3.43 (3.07-3.84) Level II 2.07 (1.86-2.29) 2.07 (1.87-2.29) 2.06 (1.87-2.27) 2.11 (1.92-2.31) 2.04 (1.86-2.22) Level III 1 1 1 1 1
Appendix
2012-2013 (n=2,178)
2014-2015 (n=2,087)
Total (n=10,781)
37.4% (30.8-44.5%) 32.8% (29.1-36.7%) 25.7% (23.2-28.3%) 14.2% (10.1-19.3%)
36.7% (29.4-44.4%) 36.2% (32.5-40.1%) 24.9% (22.3-27.7%) 16.3% (11.9-21.4%)
37.9% (34.9-41.0%) 35.2% (33.5-36.9%) 28.1% (26.9-29.4%) 15.0% (13.2-16.9%)
31.2% (27.5-35.0%) 26.1% (23.9-28.3%)
32.4% (28.7-36.3%) 26.6% (24.4-29.0%)
34.0% (32.3-35.7%) 27.4% (26.4-28.4%)
42.0% (37.5-46.6%) 29.5% (26.5-32.6%) 16.9% (14.4-19.7%) 27.5% (25.6-29.4%)
41.5% (37.1-46.0%) 32.1% (28.9-35.5%) 16.3% (13.8-19.1%) 28.3% (26.4-30.3%)
43.4% (41.3-45.5%) 31.9% (30.5-33.3%) 18.4% (17.2-19.6%) 29.2% (28.4-30.1%)
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Table A1. Proportion of nursing home residents dying in a hospital (with 95% CI), by year of death 2006-2007 2008-2009 2010-2011 (n=2,109) (n=2,256) (n=2,151) Age groups 65-74 yrs. 39.0% (32.4-45.9%) 37.8% (31.4-44.6%) 38.2% (31.3-45.5%) 75-84 yrs. 37.5% (33.5-41.7%) 37.6% (33.9-41.5%) 31.7% (28.2-35.5%) 85-94 yrs. 28.6% (25.8-31.5%) 29.5% (26.7-32.4%) 32.3% (29.4-35.4%) 95+ yrs. 17.5% (13.6-22.0%) 14.0% (10.6-18.1%) 13.1% (9.7-17.3%) Sex Male 35.3% (31.3-39.5%) 37.6% (33.8-41.5%) 33.4% (29.7-37.3%) Female 28.5% (26.2-30.8%) 27.4% (25.2-29.6%) 28.3% (26.0-30.6%) Level of care at death None/Level I 46.9% (41.5-52.2%) 46.2% (41.4-51.0%) 41.4% (37.0-46.0%) Level II 33.8% (30.9-36.9%) 31.9% (29.0-34.9%) 32.1% (29.0-35.2%) Level III 18.2% (15.5-21.1%) 20.2% (17.5-23.0%) 20.2% (17.5-23.2%) Total 30.3% (28.3-32.3%) 30.2% (28.3-32.2%) 29.8% (27.8-31.7%)
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Table A2. Proportion of nursing home residents with at least one hospitalization in the last 3 days of life (with 95% CI), by year of death 2006-2007 2008-2009 2010-2011 2012-2013 2014-2015 (n=2,109) (n=2,256) (n=2,151) (n=2,178) (n=2,087) Age groups 65-74 yrs. 41.3% (34.6-48.2%) 38.7% (32.3-45.5%) 41.4% (34.3-48.7%) 41.4% (34.5-48.5%) 37.9% (30.5-45.6%) 75-84 yrs. 40.5% (36.5-44.7%) 40.1% (36.3-44.0%) 34.4% (30.7-38.2%) 36.9% (33.1-40.9%) 38.9% (35.1-42.7%) 85-94 yrs. 31.0% (28.1-34.0%) 31.3% (28.4-34.2%) 34.8% (31.8-37.9%) 28.0% (25.4-30.7%) 27.1% (24.4-29.9%) 95+ yrs. 19.3% (15.2-23.9%) 15.4% (11.9-19.6%) 14.3% (10.7-18.6%) 14.6% (10.4-19.8%) 19.0% (14.4-24.4%) Sex Male 38.8% (34.7-43.1%) 39.8% (35.9-43.7%) 26.5% (32.7-40.4%) 34.8% (31.0-38.7%) 35.4% (31.6-39.3%) Female 30.6% (28.3-32.9%) 29.0% (26.8-31.3%) 30.4% (28.1-32.7%) 28.5% (26.3-30.8%) 28.7% (26.4-31.0%) Level of care at death None/Level I 50.9% (45.5-56.2%) 49.2% (44.4-54.0%) 45.2% (40.7-49.9%) 45.9% (41.3-50.5%) 45.6% (41.1-50.2%) Level II 36.5% (33.5-39.6%) 33.8% (30.8-36.8%) 34.3% (31.2-37.5%) 31.8% (28.8-35.0%) 34.5% (31.2-37.9%) Level III 19.6% (16.8-22.6%) 21.2% (18.5-24.2%) 21.8% (19.0-24.9%) 19.5% (16.8-22.4%) 17.5% (14.9-20.3%) Total 32.7% (30.7-34.8%) 32.0% (30.1-34.0%) 32.1% (30.2-34.1%) 30.3% (28.3-32.3%) 30.6% (28.6-32.6%)
Total (n=10,781) 40.2% (37.1-43.3%) 38.1% (36.4-39.8%) 30.3% (29.1-31.6%) 16.5% (14.7-18.5%) 37.0% (35.3-38.8%) 29.4% (28.4-30.5%) 47.1% (45.0-49.2%) 34.2% (32.8-35.6%) 19.9% (18.7-21.2%) 31.6% (30.7-32.4%)
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Table A3. Proportion of nursing home residents with at least one hospitalization in the last 7 days of life (with 95% CI), by year of death 2006-2007 2008-2009 2010-2011 2012-2013 2014-2015 (n=2,109) (n=2,256) (n=2,151) (n=2,178) (n=2,087) Age groups 65-74 yrs. 45.5% (38.7-52.2%) 45.0% (38.4-51.8%) 45.5% (38.3-52.9%) 45.8% (38.8-52.9%) 43.8% (36.2-51.6%) 75-84 yrs. 44.8% (40.6-49.0%) 44.4% (40.5-48.3%) 39.8% (36.0-43.6%) 41.7% (37.7-45.7%) 42.9% (39.0-46.8%) 85-94 yrs. 34.6% (31.6-37.7%) 34.9% (31.9-37.9%) 38.5% (35.4-41.6%) 32.1% (29.3-34.9%) 32.5% (29.6-35.4%) 95+ yrs. 22.3% (17.9-27.1%) 18.5% (14.6-23.0%) 16.5% (12.6-20.9%) 16.3% (11.9-21.6%) 22.2% (17.2-27.9%) Sex Male 44.0% (39.7-48.2%) 43.9% (40.0-47.9%) 41.5% (37.6-45.5%) 41.2% (37.3-45.2%) 40.5% (36.5-44.5%) Female 33.8% (31.5-36.3%) 33.0% (30.7-35.3%) 33.9% (31.6-36.4%) 31.6% (29.3-34.0%) 33.3% (30.9-35.7%) Level of care at death None/Level I 54.9% (49.5-60.2%) 53.1% (48.3-57.9%) 51.4% (46.8-56.0%) 51.8% (47.2-56.4%) 50.6% (46.1-55.2%) Level II 40.7% (37.6-43.8%) 38.4% (35.4-41.5%) 37.6% (34.4-40.9%) 36.0% (32.9-39.3%) 40.0% (36.6-43.5%) Level III 22.7% (19.8-25.8%) 24.5% (21.6-27.5%) 25.4% (22.4-28.6%) 22.2% (19.4-25.2%) 21.3% (18.5-24.3%) Total 36.5% (34.4-38.6%) 36.0% (34.1-38.1%) 36.1% (34.1-38.2%) 34.3% (32.3-36-3%) 35.4% (33.3-37.5%)
Total (n=10,781) 45.2% (42.1-48.3%) 42.7% (40.9-44.4%) 34.4% (33.1-35.7%) 19.2% (17.2-21.3%) 42.2% (40.4-44.0%) 33.1% (32.1-34.2%) 52.2% (50.1-54.3%) 38.6% (37.2-40.0%) 23.2% (21.9-24.6%) 35.7% (34.8-36.6%)
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Table A4. Proportion of nursing home residents with at least one hospitalization in the last 14 days of life (with 95% CI), by year of death 2006-2007 2008-2009 2010-2011 2012-2013 2014-2015 (n=2,109) (n=2,256) (n=2,151) (n=2,178) (n=2,087) Age groups 65-74 yrs. 51.2% (44.3-58.1%) 52.7% (45.9-59.4%) 51.3% (44.0-58.6%) 52.7% (45.6-59.7%) 46.7% (39.0-54.6%) 75-84 yrs. 49.7% (45.5-53.9%) 47.6% (43.7-51.5%) 46.7% (42.8-50.6%) 47.8% (43.7-51.8%) 48.8% (44.8-52.7%) 85-94 yrs. 40.7% (37.7-43.9%) 40.5% (37.5-43.6%) 43.2% (40.1-46.4%) 38.8% (35.9-41.7%) 38.1% (35.1-41.2%) 95+ yrs. 27.9% (23.2-33.0%) 23.0% (18.8-27.8%) 21.0% (16.8-25.9%) 23.0% (17.8-28.9%) 25.8% (20.5-31.7%) Sex Male 49.1% (44.8-53.4%) 49.9% (45.9-53.9%) 48.8% (44.8-52.8%) 46.8% (42.8-50.9%) 47.2% (43.2-51.3%) Female 39.7% (37.3-42.2%) 37.5% (35.2-39.9%) 38.7% (36.3-41.2%) 38.6% (36.1-41.0%) 37.9% (35.5-40.5%) Level of care at death None/Level I 60.6% (55.2-65.7%) 59.7% (54.9-64.4%) 56.9% (52.3-61.4%) 60.1% (55.5-64.5%) 55.8% (51.2-60.3%) Level II 47.5% (44.3-50.6%) 43.8% (40.7-46.9%) 44.8% (41.5-8.2%) 42.7% (39.5-46.1%) 45.2% (41.7-48.6%) Level III 27.0% (23.9-30.3%) 28.2% (25.1-31.3%) 28.9% (25.8-32.2%) 27.6% (24.6-30.8%) 26.7% (23.7-29.9%) Total 42.2% (40.0-44.3%) 41.0% (39.0-43.1%) 41.6% (39.5-43.7%) 40.9% (38.8-43.0%) 40.6% (38.5-42.8%)
Total (n=10,781) 51.1% (48.0-54.2%) 48.1% (46.3-49.8%) 40.2% (38.9-41.6%) 24.1% (22.0-26.4%) 48.4% (46.6-50.2%) 38.5% (37.4-39.6%) 58.5% (56.4-60.5%) 44.8% (43.4-46.3%) 27.7% (26.3-29.1%) 41.2% (40.3-42.2%)
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Table A5. Proportion of nursing home residents with at least one hospitalization in the last 30 days of life (with 95% CI), by year of death 2006-2007 2008-2009 2010-2011 2012-2013 2014-2015 (n=2,109) (n=2,256) (n=2,151) (n=2,178) (n=2,087) Age groups 65-74 yrs. 59.2% (52.2-65.8%) 60.8% (54.1-67.3%) 58.6% (51.3-65.7%) 62.6% (55.5-69.2%) 56.2% (48.4-63.8%) 75-84 yrs. 57.7% (53.5-61.8%) 56.2% (52.3-60.1%) 55.5% (51.6-59.3%) 54.9% (50.8-58.9%) 56.3% (52.4-60.2%) 85-94 yrs. 46.4% (43.2-49.5%) 47.5% (44.4-50.6%) 50.9% (47.7-54.0%) 46.5% (43.6-49.5%) 46.4% (43.3-49.5%) 95+ yrs. 33.2% (28.2-38.5%) 28.7% (24.0-33.7%) 27.1% (22.4-32.3%) 28.0% (22.4-34.2%) 32.1% (26.4-38.3%) Sex Male 56.4% (52.1-60.6%) 58.6% (54.7-62.5%) 57.4% (53.3-61.3%) 56.2% (52.1-60.1%) 56.4% (52.4-60.4%) Female 45.9% (43.4-48.4%) 44.4% (41.9-46.8%) 46.1% (43.6-48.6%) 45.3% (42.8-47.8%) 45.3% (42.7-47.9%) Level of care at death None/Level I 66.3% (61.1-71.2%) 67.1% (62.5-71.6%) 65.8% (61.3-70.0%) 68.2% (63.7-72.3%) 64.3% (59.9-68.6%) Level II 54.3% (51.1-57.4%) 51.7% (48.5-54.8%) 52.7% (49.4-56.0%) 50.1% (46.8-53.4%) 52.1% (48.7-55.6%) Level III 33.3% (30.0-36.8%) 34.8% (31.6-38.2%) 35.7% (32.4-39.2%) 34.8% (31.5-38.2%) 35.2% (31.9-38.6%) Total 48.6% (46.4-50.8%) 48.4% (46.3-50.4%) 49.3% (47.2-51.5%) 48.3% (46.2-50.4%) 48.5% (46.4-50.7%)
Total (n=10,781) 59.6% (56.5-62.7%) 56.1% (54.3-57.8%) 47.5% (46.1-48.9%) 29.8% (27.5-32.2%) 57.0% (55.2-58.8%) 45.4% (44.3-46.5%) 66.3% (64.3-68.3%) 52.2% (50.7-53.7%) 34.8% (33.3-36.3%) 48.6% (47.7-49.6%)
PII:
S0378-5122(19)30842-4
DOI:
https://doi.org/10.1016/j.maturitas.2020.02.006
Reference:
MAT 7299
To appear in:
Maturitas
Received Date:
21 September 2019
Revised Date:
3 February 2020
Accepted Date:
18 February 2020
Please cite this article as: Hoffmann F, Allers K, Ten-year trends in end-of-life hospitalizations of nursing home residents in Germany, 2006-2015, Maturitas (2020), doi: https://doi.org/10.1016/j.maturitas.2020.02.006
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Ten-year trends in end-of-life hospitalizations of nursing home residents in Germany, 2006-2015 Running title: End-of-life hospitalizations of nursing home residents Falk Hoffmann1, Katharina Allers1 1
Carl von Ossietzky University Oldenburg, Department of Health Services Research, Oldenburg, Germany Corresponding author: Prof. Dr. Falk Hoffmann, MPH
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Carl von Ossietzky University Oldenburg Department of Health Services Research Ammerländer Heerstr. 140 D- 26129 Oldenburg, Germany Phone: +49 441/ 798- 2880
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E-mail: [email protected]
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Fax: +49 441/ 798- 5824
Highlights
End-of-life hospitalizations of nursing home residents are common in Germany.
We found a small decrease over recent years in the proportion of in-hospital deaths and no significant differences in hospitalization rates during the last 7, 14 and 30 days of life over a 10-year period.
The length of terminal hospitalizations decreased over time.
More studies should examine longitudinal trends.
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Abstract
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Objectives: We investigated trends in end-of-life hospitalizations among nursing home residents (NHR) over 10 years and looked at differences between age groups and sexes as well as the length of terminal hospital stays. Study design: Retrospective cohort study based on health insurance claims data of the AOK Bremen/Bremerhaven. All NHR aged 65 years or more who died between 2006 and 2015 were included.
2 Main outcome measures: We assessed the proportions of decedents who were in hospital on the day of death and during the last 3, 7, 14 and 30 days of life, stratified by two-year periods. Multiple logistic regressions were conducted to study changes over time, adjusting for covariates. Results: A total of 10,781 decedents were included (mean age 86.1 years, 72.1% females). Overall, 29.2% died in hospital, with a slight decrease from 30.3% in 20062007 to 28.3% in 2014-2015 (OR 0.86; 95% CI 0.75-0.98). Of the 3,150 terminal
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hospitalizations, 35.5% lasted up to 3 days and the mean length of stay decreased from 9.0 (2006-2007) to 7.5 days (2014-2015). When looking at the last 7, 14 and 30 days of life, no changes over time were found. Male sex and younger age were
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associated with a higher chance of end-of-life hospitalization in all analyses.
Conclusions: End-of-life hospitalizations of NHR are common in Germany. There has
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been a small decrease during recent years in the proportion of in-hospital deaths, but
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not of hospitalizations during the last 7, 14 and 30 days of life. This might be explained
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by shorter durations of hospital stays.
Keywords: Nursing homes, health services research, end-of-life care, long-term care,
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hospital use
1. Introduction During the last weeks of life, hospitalization rates of nursing home residents (NHR) increase substantially [1,2] and the proportion of in-hospital deaths ranges between 5.9% and 77.1% with large variations between countries [3]. Generally, it is critically discussed
whether
benefits
of
hospitalizations
outweigh
potential
negative
3 consequences for NHR [4,5]. This is especially the case for end-of-life hospitalizations, as residents dying soon after admission may not benefit from hospitalization [5,6]. As palliative approaches and advance directives are more common during recent years in nursing homes [7,8], one might suggest that there are also changes in endof-life hospitalizations of residents. However, only very few studies were conducted regarding this question. In a recent and comprehensive systematic review we only
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found 4 studies assessing trends over time [3]. All these data come from the United States (US) analyzing trends over 5, 9 or 10 years up to 2009 [9–12]. These studies assessed different periods before death and in two of them the proportion of NHR with
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end-of-life hospitalizations remained virtually unchanged [10,11], whereas one study found that the likelihood of in-hospital death even increased in a multivariable analysis
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[9]. Another study also reported an increase in hospitalizations during the last month of life from 24.8% in 2000 to 33.3% in 2009 [12]. Moreover, few studies have assessed
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the duration of terminal hospital stays, but these have reported a high proportion of
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people who died within the first three days of admission [13]. Taking together, the few studies assessing trends over time in end-of-life hospitalizations of NHRs showed mixed findings. No studies with data after 2009,
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assessing several different periods before death or from countries other than the US
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are available. For Germany, an indirect comparison of two studies suggest no difference in the proportion of in-hospital deaths of NHR from 2000-2001 (28.9%) [14] to 2010-2014 (29.5%) [1]. However, first of all, these studies used data of different health insurance funds. It is known that there are differences in morbidity and health services use including hospitalizations between members of different funds [15,16]. Furthermore, one of these studies included a regional sample and evidence from the
4 US and from France showed substantial regional variations of in-hospital deaths among NHR [9,17]. Therefore, the primary objective of this study was to investigate trends of end-of-life hospitalizations of NHR in Germany over 10 years using one and the same database. Our secondary objective was to study differences between age groups and sexes as well as the length of terminal hospital stays. All analyses were conducted for different periods within the last month of life.
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2. Methods
This retrospective cohort study is part of the large publicly funded project ‘HOMERN’ (Hospitalization and emergency department visits of nursing home residents) which
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2.1 Database, study population and outcome
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aims to explore health care of NHR with a focus on hospital transfers.
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We used administrative data of the AOK Bremen/Bremerhaven. With about 0.7 million inhabitants Bremen is the smallest of the 16 German federal states and the AOK
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Bremen/Bremerhaven insures about one third of this population. The study population included all NHR insured by the AOK Bremen/Bremerhaven that
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died between January 1, 2006, and December 31, 2015 and being aged 65+ years at death. No further inclusion or exclusion criteria were applied.
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Data on hospitalizations and on long-term care (‘‘Gesetzliche Pflegeversicherung’’) were available. Data on long-term care included information on nursing home placement and on levels of care dependency. These levels of care dependency range from care level I (considerable need of care) to care level III (most heavily care dependent) and are assigned by an independent authority. Care levels were used as an indicator of physical disabilities, which was also done in previous studies [18,19].
5 We assessed care levels at the day of death. Further information on the German longterm care as well as the health care system in total are available in Busse and Blümel [20]. Our outcome of interest was the proportion of decedents being in hospital at least once during the following end-of-life periods: the day of death (in-hospital death) as well as the last 3, 7, 14 and 30 days of life. Year of death, as our main independent variable, was divided in two-year periods
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(2006-2007, 2008-2009, 2010-2011, 2012-2013 and 2014-2015). 2.2 Statistical analysis
First, we compared baseline characteristics by year of death. Second, we calculated
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proportions with at least one hospitalization during the 5 end-of-life periods by year of
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death and estimated 95% confidence intervals (95% CIs) with the exact (ClopperPearson) method. Third, we fitted separate multiple logistic regression models for each
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of the 5 end-of-life periods to estimate odds ratios (OR) with 95% CI adjusting for covariates. Besides year of death (5 categories), we included sex (2 categories), age
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at the time of death (65-74, 75-84, 85-94 and 95+ years) and level of care dependency at the time of death (3 categories) in these multiple adjusted models. Fourth, we
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analysed durations of the hospitalization by year of death. All p-values less than 0.05 and non-overlapping 95% CI were considered statistically
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significant. Analyses were conducted with SAS for Windows version 9.4 (SAS Institute Inc, Cary, North Carolina). This study received a waiver from the medical ethics committee of the Carl von Ossietzky University of Oldenburg (2017-054).
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3. Results 3.1 Baseline characteristics A total of 10,781 NHR died between 2006 and 2015. They were on average 86.1 (SD: 7.9) years old, and about three quarter were female (72.1%). Most had care level II at the day of death (42.4%). The number of deaths ranged between 2,087 and 2,256 for the 5 two-year periods
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(Table 1). Mean age did not change through the years, but the proportion of males increased from 25.9% to 29.1% as did the proportion with low need of care (none/ levels I) from 16.6% to 23.1% (2006-2007 to 2014-2015).
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3.2 Hospitalizations at the end of life
Overall, the proportion of in-hospital deaths was 29.2% (Table 2). This proportion
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decreased slightly over time from 30.3% to 28.3% (2006-2007 to 2014-2015). As
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shown in Table 3, this is also supported by the multivariable analyses adjusting for covariates (OR: 0.86; 95% CI: 0.75-0.98).
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During the last 3, 7 and 14 days of life the proportions of NHR with at least one hospitalization were 31.6%, 35.7% and 41.2%, respectively (Table 2). A significant
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decrease over the years 2006-2007 to 2014-2015 was only found for the last 3 days of life (OR: 0.85; 95% CI: 0.74-0.97) and in none of the further analysed periods (Table
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3).
The proportion of NHR with at least one hospitalization during the last 30 days of life was 48.6% (Table 2). This proportion remained unchanged over time with 48.6% and 48.5% (2006-2007 to 2014-2015) and no significant association was found when adjusting for covariates, too (OR: 0.94; 95% CI: 0.83-1.06).
7 3.3 Differences in end-of-life hospitalization between age and sex There were large differences for age groups as well as for care levels. Overall, the proportion of in-hospital deaths decreases slightly from 37.9% in persons aged 65-74 years to 35.2% in persons aged 75-84 years and declines thereafter to 28.1% and 15.0% in those aged 85-94 and 95+ years. For care levels, a linear decrease of residents dying in a hospital was found from 43.4% (none/ level I) to 31.9% (level II) and 18.4% (level III). Males died more often in a hospital than women (34.0% vs.
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27.4%). These patterns for age groups, care levels and sex were found for all two-year periods, as shown in Table A1.
The same patterns as for in-hospital death were also found for hospitalizations during
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the last 3, 7, 14 and 30 days of life (Tables 2, A2-5). A total of 66.3% of residents with a low care level (none/ level I) were hospitalized at least once during the last 30 days
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of life, 52.2% with level II and 34.8% with level III (Table 2). This proportion was 59.6%
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and 56.1% in persons aged 65-74 and 75-84 years, respectively, and declines thereafter to 47.5% and 29.8% in NHR aged 85-94 and 95+ years. Differences
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between sexes were found (males: 57.0% and females: 45.4%). Again, these patterns were consistent for all two-year periods analysed.
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The multivariable analyses confirm these findings described above (Table 3). 3.4 Duration of terminal hospitalization
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The 3,150 terminal hospitalizations lasted on average 7.9 days (SD: 8.5) with a substantial decrease over time from 9.0 days (SD: 9.6) in 2006-2007 to 7.5 days (SD: 7.9) in 2014-2015. This decline was not linear, as the mean was 9.0 and 8.2 days up to 2009 and ranged between 7.3-7.5 days for the 3 two-year periods thereafter.
8 Overall, length of stay was 1 day in 11.0% of these hospitalizations (e.g. these patients died on the day of admission) and up to 3 days in 35.5% of decedents dying in hospital. For both measures there was no clear pattern as the length of stay of 1 day and up to 3 days ranged between 9.1-12.3% (with 10.8% in 2006-2007 and 11.0% in 2014-2015) and 30.7-39.7% (with 30.7% in 2006-2007 and 35.9% in 2014-2015) during the observation periods, respectively.
4. Discussion
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This is the first study assessing trends in end-of-life hospitalizations of NHR from another country than the US and the first analysing data up to 2015. Including more than 10,000 decedent NHR, we found that only in-hospital deaths decreased slightly
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during the observed period. No significant differences for hospitalization during the last 7, 14 and 30 days could be observed. Almost half of all deceased residents were in
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hospital during the last month of life. We found noticeable differences between sexes
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with male NHR having a higher chance of end-of-life hospitalizations in all assessed periods. Younger age and a lower level of care were associated with an increased
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likelihood of end-of-life hospitalizations. The length of terminal hospitalizations decreased over time and over one third of hospitalized residents died within three days
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after admission.
4.1 Comparison with other studies and interpretation
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It is evident that terminal hospitalizations are often burdensome for residents and their relatives and often result in adverse consequences [5,21]. However, with almost half of decedent NHR hospitalized in the last month of life and 30% dying in hospital, a high proportion of German residents is been transferred to hospital shortly before death. Overall, the hospitalization rates found in our study are higher compared to the median of 22.6% of in-hospital death and 33.2% of hospitalization during the last month of life
9 found in our recent systematic review that included all published studies worldwide with most being from the US [3]. Reasons for these differences might be explained by multiple factors, for example, resources available in the nursing home, availability of physicians or differences in qualifications of nurses or interprofessional communication between care providers [22]. Additionally, previous research showed that advance care planning and advance directives as do-not-hospitalize orders lead to a reduction of end-of-life hospitalizations [23–25]. Though advance care planning and palliative care
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approaches have become more common over the last years, in Germany, they are still rare [26–28].
No major differences in end-of-life hospitalizations could be observed in a period of ten
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years. Although the proportion dying in hospital decreased from 30.3% to 28.3% with a statistically significant difference when adjusting for covariates in the multivariable
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logistic regression, we found no significant difference for hospitalizations during the last month or weeks of life. This might be explained by decreasing lengths of hospital
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stay. Our findings are consistent with two prior studies from the US that found inhospital deaths and end-of-life hospitalizations remaining virtually unchanged over 5
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year and 9 year periods [10,11]. One study from the US even found increasing odds of NHR dying in hospitals over a five year period [9] and one study found an increased
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proportion of hospitalizations during the last month of life over a period of ten years
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[12]. Overall, there seem to be no decline in end-of-life hospitalizations in NHR. However, despite the importance of this topic there is little research conducted on longitudinal trends [3]. Again, we found noticeable differences between sexes with males having a higher chance of end-of-life hospitalizations compared to females in quite all assessed periods. This is well in line with the literature on overall hospitalizations of nursing home
10 residents, as our systematic review shows [29]. However, reasons for this are still unclear. A Canadian study hypothesized that the sex differences in end-of-life burdensome interventions are associated with sociocultural factors. Some possible explanations discussed by the authors are that women take more often part in advance care planning and discuss their preferences and wishes more often with their relatives, and are less afraid of death. Moreover, men might be more likely to have a wife who advocates for their care leading to a more aggressive treatments [30].
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Further, younger age and a lower level of care were associated with an increased likelihood of being in hospital during the last month of life and dying in hospital. These patterns were found in all years and the findings are similar to those from other studies
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[31–33]. This might indicate less aggressive end-of-life treatment in older and more care dependent residents.
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The length of terminal hospitalizations decreased over the years with an average
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length of hospital stay of 7.9 days (2006-2007: 9.0 days to 2014-2015: 7.5 days). To our knowledge this is the first study analyzing time trends concerning length of stay of
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terminal hospitalizations. In our recent systematic review, we only found four studies assessing the time spent in hospital before death at all [3] and none of them analyzed trends. More than one third of residents included in our study died within three days of
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admission with no clear pattern over time. This result is in line with an earlier study
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from Germany [14]. With regard to prior research which defined hospitalizations within three days likely to be manageable in the nursing home [34] and potentially burdensome [35], the proportion of 35.5% seems to be quite high. Interestingly, in a recent survey among general practitioners within the HOMERN project, 71.1% also agreed that NHR are treated in hospital too often at the end of life [36]. This underlines the need for improvement. A higher nurse staffing as well as better
11 training in palliative care for nurses as well as general practitioners were seen as important measures to improve end-of-life care among nursing home residents among respondents of this survey [36]. 4.2 Strengths and limitations The main strengths of this study were the large sample size of more than 10,000 decedents and the opportunity to assess trends over a 10 years period using one and the same database. We had access to administrative data and were able to study end-
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of-life hospitalizations without the typical shortcomings of field studies like nonresponse or recall bias.
Several limitations have to be considered as well. First, no facility characteristics could
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be analysed, which have been found to influence the decision to hospitalize [17,22]. In
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a recent study conducted in 21 German nursing homes, we also found variations in the proportion of residents being hospitalized at least once during the last 12 months
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between 20-74% [37]. However, facility characteristics including data on which residents come from which nursing home are generally not available in German health
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insurance claims data. Second, we did not have access to further clinical characteristics of residents, e.g. whether they had advance directives or how there
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cognitive or overall health status were. However, data on care levels at death were available, which is an indicator of physical disabilities [18,19]. Further, we also had no
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information about causes of death. Finally, we used data of just one regional health insurance fund. Compared to other funds, the AOK insures a lower educated population with a generally high burden of chronic diseases including high hospitalization rates [15,16].
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5. Conclusions In Germany the proportion of NHR being hospitalized shortly before death is high with no substantial change over a ten year period. Taken the available evidence together, there seem to be no decline in end-of-life hospitalizations of NHR in the US as well as in Germany during recent years. But overall, there is little research on trends over time and none from other than these two countries. More future studies should examine longitudinal trends, especially as a more widely implementation of advance care
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planning or palliative approaches should change the quality of end-of-life care and decrease burdensome hospitalizations shortly before death.
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Contributors
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Falk Hoffmann conceptualized the study, conducted the analyses and drafted the
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manuscript.
Katharina Allers conceptualized the study and conducted the analyses.
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the final version.
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Both authors interpreted the data, critically revised the manuscript, read and approved
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Conflict of interest
The authors declare that they have no conflict of interest.
Funding The project on which this publication is based was funded by the Innovation Committee at the Federal Joint Committee (Innovationsausschuss beim Gemeinsamen
13 Bundesausschuss; FKZ: 01VSF16055). We thank the AOK Bremen/Bremerhaven for providing the data.
Ethical approval This study received a waiver from the medical ethics committee of the Carl von
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Ossietzky University of Oldenburg (2017-054).
Provenance and peer review
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This article has undergone peer review.
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Research data (data sharing and collaboration)
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19 2014-2015 (n=2,087) 86.1±7.7
Total (n=10,781) 86.1±7.9
9.3% 27.9% 51.8% 11.0%
8.1% 31.0% 48.9% 12.1%
9.3% 28.9% 47.8% 14.0%
28.0% 72.0%
29.1% 70.9%
27.9% 72.1%
21.6% 41.1% 37.2%
23.1% 39.1% 37.9%
20.5% 42.4% 37.1%
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2012-2013 (n=2,178) 86.1±7.7
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Table 1. Baseline characteristics of decedents, by year of death 2006-2007 2008-2009 2010-2011 (n=2,109) (n=2,256) (n=2,151) Mean age at death±SD 86.3±8.1 86.0±8.0 86.2±7.9 Age groups 65-74 yrs. 10.1% 9.8% 8.9% 75-84 yrs. 26.8% 28.9% 30.2% 85-94 yrs. 47.1% 45.5% 45.7% 95+ yrs. 16.0% 15.8% 15.2% Sex Male 25.9% 28.0% 28.8% Female 74.1% 72.0% 71.2% Level of care at death None/Level I 16.6% 19.0% 22.0% Level II 46.8% 43.8% 41.2% Level III 36.6% 37.1% 36.8%
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Table 2. Proportion of nursing home residents with at least one end-of-life hospitalization (with 95% CI), by periods before death Day of death Last 3 days Last 7 days Last 14 days (n=10,781) (n=10,781) (n=10,781) (n=10,781) Year of death 2006-2007 30.3% (28.3-32.3%) 32.7% (30.7-34.8%) 36.5% (34.4-38.6%) 42.2% (40.0-44.3%) 2008-2009 30.2% (28.3-32.2%) 32.0% (30.1-34.0%) 36.0% (34.1-38.1%) 41.0% (39.0-43.1%) 2010-2011 29.8% (27.8-31.7%) 32.1% (30.2-34.1%) 36.1% (34.1-38.2%) 41.6% (39.5-43.7%) 2012-2013 27.5% (25.6-29.4%) 30.3% (28.3-32.3%) 34.3% (32.3-36-3%) 40.9% (38.8-43.0%) 2014-2015 28.3% (26.4-30.3%) 30.6% (28.6-32.6%) 35.4% (33.3-37.5%) 40.6% (38.5-42.8%) Age groups 65-74 yrs. 37.9% (34.9-41.0%) 40.2% (37.1-43.3%) 45.2% (42.1-48.3%) 51.1% (48.0-54.2%) 75-84 yrs. 35.2% (33.5-36.9%) 38.1% (36.4-39.8%) 42.7% (40.9-44.4%) 48.1% (46.3-49.8%) 85-94 yrs. 28.1% (26.9-29.4%) 30.3% (29.1-31.6%) 34.4% (33.1-35.7%) 40.2% (38.9-41.6%) 95+ yrs. 15.0% (13.2-16.9%) 16.5% (14.7-18.5%) 19.2% (17.2-21.3%) 24.1% (22.0-26.4%) Sex Male 34.0% (32.3-35.7%) 37.0% (35.3-38.8%) 42.2% (40.4-44.0%) 48.4% (46.6-50.2%) Female 27.4% (26.4-28.4%) 29.4% (28.4-30.5%) 33.1% (32.1-34.2%) 38.5% (37.4-39.6%) Level of care at death None/Level I 43.4% (41.3-45.5%) 47.1% (45.0-49.2%) 52.2% (50.1-54.3%) 58.5% (56.4-60.5%) Level II 31.9% (30.5-33.3%) 34.2% (32.8-35.6%) 38.6% (37.2-40.0%) 44.8% (43.4-46.3%) Level III 18.4% (17.2-19.6%) 19.9% (18.7-21.2%) 23.2% (21.9-24.6%) 27.7% (26.3-29.1%) Total 29.2% (28.4-30.1%) 31.6% (30.7-32.4%) 35.7% (34.8-36.6%) 41.2% (40.3-42.2%)
Last 30 days (n=10,781) 48.6% (46.4-50.8%) 48.4% (46.3-50.4%) 49.3% (47.2-51.5%) 48.3% (46.2-50.4%) 48.5% (46.4-50.7%) 59.6% (56.5-62.7%) 56.1% (54.3-57.8%) 47.5% (46.1-48.9%) 29.8% (27.5-32.2%) 57.0% (55.2-58.8%) 45.4% (44.3-46.5%) 66.3% (64.3-68.3%) 52.2% (50.7-53.7%) 34.8% (33.3-36.3%) 48.6% (47.7-49.6%)
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Table 3. Multivariable logistic regression for factors associated with end-of-life hospitalizations of nursing home residents, by periods before death Day of death Last 3 days Last 7 days Last 14 days Last 30 days (n=10,781) (n=10,781) (n=10,781) (n=10,781) (n=10,781) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Year of death 2006-2007 1 1 1 1 1 2008-2009 0.98 (0.86-1.12) 0.95 (0.83-1.08) 0.96 (0.85-1.09) 0.93 (0.82-1.06) 0.97 (0.86-1.10) 2010-2011 0.94 (0.82-1.08) 0.93 (0.82-1.06) 0.94 (0.83-1.07) 0.94 (0.82-1.06) 0.99 (0.87-1.12) 2012-2013 0.83 (0.72-0.95) 0.84 (0.73-0.96) 0.85 (0.75-0.97) 0.89 (0.79-1.02) 0.93 (0.82-1.06) 2014-2015 0.86 (0.75-0.98) 0.85 (0.74-0.97) 0.89 (0.78-1.02) 0.88 (0.77-1.00) 0.94 (0.83-1.06) Age groups 65-74 yrs. 3.00 (2.46-3.67) 2.89 (2.37-3.51) 2.91 (2.41-3.51) 2.72 (2.27-3.26) 2.81 (2.35-3.36) 75-84 yrs. 2.78 (2.36-3.27) 2.78 (2.37-3.26) 2.77 (2.38-3.23) 2.56 (2.22-2.95) 2.61 (2.28-2.99) 85-94 yrs. 2.05 (1.75-2.40) 2.02 (1.74-2.35) 2.02 (1.75-2.33) 1.93 (1.69-2.20) 1.93 (1.70-2.19) 95+ yrs. 1 1 1 1 1 Sex Male 1.09 (0.99-1.20) 1.13 (1.02-1.24) 1.18 (1.07-1.29) 1.21 (1.10-1.32) 1.28 (1.17-1.40) Female 1 1 1 1 1 Level of care at death None/Level I 3.19 (2.84-3.59) 3.36 (2.99-3.77) 3.38 (3.02-3.78) 3.44 (3.08-3.84) 3.43 (3.07-3.84) Level II 2.07 (1.86-2.29) 2.07 (1.87-2.29) 2.06 (1.87-2.27) 2.11 (1.92-2.31) 2.04 (1.86-2.22) Level III 1 1 1 1 1
Appendix
2012-2013 (n=2,178)
2014-2015 (n=2,087)
Total (n=10,781)
37.4% (30.8-44.5%) 32.8% (29.1-36.7%) 25.7% (23.2-28.3%) 14.2% (10.1-19.3%)
36.7% (29.4-44.4%) 36.2% (32.5-40.1%) 24.9% (22.3-27.7%) 16.3% (11.9-21.4%)
37.9% (34.9-41.0%) 35.2% (33.5-36.9%) 28.1% (26.9-29.4%) 15.0% (13.2-16.9%)
31.2% (27.5-35.0%) 26.1% (23.9-28.3%)
32.4% (28.7-36.3%) 26.6% (24.4-29.0%)
34.0% (32.3-35.7%) 27.4% (26.4-28.4%)
42.0% (37.5-46.6%) 29.5% (26.5-32.6%) 16.9% (14.4-19.7%) 27.5% (25.6-29.4%)
41.5% (37.1-46.0%) 32.1% (28.9-35.5%) 16.3% (13.8-19.1%) 28.3% (26.4-30.3%)
43.4% (41.3-45.5%) 31.9% (30.5-33.3%) 18.4% (17.2-19.6%) 29.2% (28.4-30.1%)
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Table A1. Proportion of nursing home residents dying in a hospital (with 95% CI), by year of death 2006-2007 2008-2009 2010-2011 (n=2,109) (n=2,256) (n=2,151) Age groups 65-74 yrs. 39.0% (32.4-45.9%) 37.8% (31.4-44.6%) 38.2% (31.3-45.5%) 75-84 yrs. 37.5% (33.5-41.7%) 37.6% (33.9-41.5%) 31.7% (28.2-35.5%) 85-94 yrs. 28.6% (25.8-31.5%) 29.5% (26.7-32.4%) 32.3% (29.4-35.4%) 95+ yrs. 17.5% (13.6-22.0%) 14.0% (10.6-18.1%) 13.1% (9.7-17.3%) Sex Male 35.3% (31.3-39.5%) 37.6% (33.8-41.5%) 33.4% (29.7-37.3%) Female 28.5% (26.2-30.8%) 27.4% (25.2-29.6%) 28.3% (26.0-30.6%) Level of care at death None/Level I 46.9% (41.5-52.2%) 46.2% (41.4-51.0%) 41.4% (37.0-46.0%) Level II 33.8% (30.9-36.9%) 31.9% (29.0-34.9%) 32.1% (29.0-35.2%) Level III 18.2% (15.5-21.1%) 20.2% (17.5-23.0%) 20.2% (17.5-23.2%) Total 30.3% (28.3-32.3%) 30.2% (28.3-32.2%) 29.8% (27.8-31.7%)
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Table A2. Proportion of nursing home residents with at least one hospitalization in the last 3 days of life (with 95% CI), by year of death 2006-2007 2008-2009 2010-2011 2012-2013 2014-2015 (n=2,109) (n=2,256) (n=2,151) (n=2,178) (n=2,087) Age groups 65-74 yrs. 41.3% (34.6-48.2%) 38.7% (32.3-45.5%) 41.4% (34.3-48.7%) 41.4% (34.5-48.5%) 37.9% (30.5-45.6%) 75-84 yrs. 40.5% (36.5-44.7%) 40.1% (36.3-44.0%) 34.4% (30.7-38.2%) 36.9% (33.1-40.9%) 38.9% (35.1-42.7%) 85-94 yrs. 31.0% (28.1-34.0%) 31.3% (28.4-34.2%) 34.8% (31.8-37.9%) 28.0% (25.4-30.7%) 27.1% (24.4-29.9%) 95+ yrs. 19.3% (15.2-23.9%) 15.4% (11.9-19.6%) 14.3% (10.7-18.6%) 14.6% (10.4-19.8%) 19.0% (14.4-24.4%) Sex Male 38.8% (34.7-43.1%) 39.8% (35.9-43.7%) 26.5% (32.7-40.4%) 34.8% (31.0-38.7%) 35.4% (31.6-39.3%) Female 30.6% (28.3-32.9%) 29.0% (26.8-31.3%) 30.4% (28.1-32.7%) 28.5% (26.3-30.8%) 28.7% (26.4-31.0%) Level of care at death None/Level I 50.9% (45.5-56.2%) 49.2% (44.4-54.0%) 45.2% (40.7-49.9%) 45.9% (41.3-50.5%) 45.6% (41.1-50.2%) Level II 36.5% (33.5-39.6%) 33.8% (30.8-36.8%) 34.3% (31.2-37.5%) 31.8% (28.8-35.0%) 34.5% (31.2-37.9%) Level III 19.6% (16.8-22.6%) 21.2% (18.5-24.2%) 21.8% (19.0-24.9%) 19.5% (16.8-22.4%) 17.5% (14.9-20.3%) Total 32.7% (30.7-34.8%) 32.0% (30.1-34.0%) 32.1% (30.2-34.1%) 30.3% (28.3-32.3%) 30.6% (28.6-32.6%)
Total (n=10,781) 40.2% (37.1-43.3%) 38.1% (36.4-39.8%) 30.3% (29.1-31.6%) 16.5% (14.7-18.5%) 37.0% (35.3-38.8%) 29.4% (28.4-30.5%) 47.1% (45.0-49.2%) 34.2% (32.8-35.6%) 19.9% (18.7-21.2%) 31.6% (30.7-32.4%)
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Table A3. Proportion of nursing home residents with at least one hospitalization in the last 7 days of life (with 95% CI), by year of death 2006-2007 2008-2009 2010-2011 2012-2013 2014-2015 (n=2,109) (n=2,256) (n=2,151) (n=2,178) (n=2,087) Age groups 65-74 yrs. 45.5% (38.7-52.2%) 45.0% (38.4-51.8%) 45.5% (38.3-52.9%) 45.8% (38.8-52.9%) 43.8% (36.2-51.6%) 75-84 yrs. 44.8% (40.6-49.0%) 44.4% (40.5-48.3%) 39.8% (36.0-43.6%) 41.7% (37.7-45.7%) 42.9% (39.0-46.8%) 85-94 yrs. 34.6% (31.6-37.7%) 34.9% (31.9-37.9%) 38.5% (35.4-41.6%) 32.1% (29.3-34.9%) 32.5% (29.6-35.4%) 95+ yrs. 22.3% (17.9-27.1%) 18.5% (14.6-23.0%) 16.5% (12.6-20.9%) 16.3% (11.9-21.6%) 22.2% (17.2-27.9%) Sex Male 44.0% (39.7-48.2%) 43.9% (40.0-47.9%) 41.5% (37.6-45.5%) 41.2% (37.3-45.2%) 40.5% (36.5-44.5%) Female 33.8% (31.5-36.3%) 33.0% (30.7-35.3%) 33.9% (31.6-36.4%) 31.6% (29.3-34.0%) 33.3% (30.9-35.7%) Level of care at death None/Level I 54.9% (49.5-60.2%) 53.1% (48.3-57.9%) 51.4% (46.8-56.0%) 51.8% (47.2-56.4%) 50.6% (46.1-55.2%) Level II 40.7% (37.6-43.8%) 38.4% (35.4-41.5%) 37.6% (34.4-40.9%) 36.0% (32.9-39.3%) 40.0% (36.6-43.5%) Level III 22.7% (19.8-25.8%) 24.5% (21.6-27.5%) 25.4% (22.4-28.6%) 22.2% (19.4-25.2%) 21.3% (18.5-24.3%) Total 36.5% (34.4-38.6%) 36.0% (34.1-38.1%) 36.1% (34.1-38.2%) 34.3% (32.3-36-3%) 35.4% (33.3-37.5%)
Total (n=10,781) 45.2% (42.1-48.3%) 42.7% (40.9-44.4%) 34.4% (33.1-35.7%) 19.2% (17.2-21.3%) 42.2% (40.4-44.0%) 33.1% (32.1-34.2%) 52.2% (50.1-54.3%) 38.6% (37.2-40.0%) 23.2% (21.9-24.6%) 35.7% (34.8-36.6%)
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Table A4. Proportion of nursing home residents with at least one hospitalization in the last 14 days of life (with 95% CI), by year of death 2006-2007 2008-2009 2010-2011 2012-2013 2014-2015 (n=2,109) (n=2,256) (n=2,151) (n=2,178) (n=2,087) Age groups 65-74 yrs. 51.2% (44.3-58.1%) 52.7% (45.9-59.4%) 51.3% (44.0-58.6%) 52.7% (45.6-59.7%) 46.7% (39.0-54.6%) 75-84 yrs. 49.7% (45.5-53.9%) 47.6% (43.7-51.5%) 46.7% (42.8-50.6%) 47.8% (43.7-51.8%) 48.8% (44.8-52.7%) 85-94 yrs. 40.7% (37.7-43.9%) 40.5% (37.5-43.6%) 43.2% (40.1-46.4%) 38.8% (35.9-41.7%) 38.1% (35.1-41.2%) 95+ yrs. 27.9% (23.2-33.0%) 23.0% (18.8-27.8%) 21.0% (16.8-25.9%) 23.0% (17.8-28.9%) 25.8% (20.5-31.7%) Sex Male 49.1% (44.8-53.4%) 49.9% (45.9-53.9%) 48.8% (44.8-52.8%) 46.8% (42.8-50.9%) 47.2% (43.2-51.3%) Female 39.7% (37.3-42.2%) 37.5% (35.2-39.9%) 38.7% (36.3-41.2%) 38.6% (36.1-41.0%) 37.9% (35.5-40.5%) Level of care at death None/Level I 60.6% (55.2-65.7%) 59.7% (54.9-64.4%) 56.9% (52.3-61.4%) 60.1% (55.5-64.5%) 55.8% (51.2-60.3%) Level II 47.5% (44.3-50.6%) 43.8% (40.7-46.9%) 44.8% (41.5-8.2%) 42.7% (39.5-46.1%) 45.2% (41.7-48.6%) Level III 27.0% (23.9-30.3%) 28.2% (25.1-31.3%) 28.9% (25.8-32.2%) 27.6% (24.6-30.8%) 26.7% (23.7-29.9%) Total 42.2% (40.0-44.3%) 41.0% (39.0-43.1%) 41.6% (39.5-43.7%) 40.9% (38.8-43.0%) 40.6% (38.5-42.8%)
Total (n=10,781) 51.1% (48.0-54.2%) 48.1% (46.3-49.8%) 40.2% (38.9-41.6%) 24.1% (22.0-26.4%) 48.4% (46.6-50.2%) 38.5% (37.4-39.6%) 58.5% (56.4-60.5%) 44.8% (43.4-46.3%) 27.7% (26.3-29.1%) 41.2% (40.3-42.2%)
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Table A5. Proportion of nursing home residents with at least one hospitalization in the last 30 days of life (with 95% CI), by year of death 2006-2007 2008-2009 2010-2011 2012-2013 2014-2015 (n=2,109) (n=2,256) (n=2,151) (n=2,178) (n=2,087) Age groups 65-74 yrs. 59.2% (52.2-65.8%) 60.8% (54.1-67.3%) 58.6% (51.3-65.7%) 62.6% (55.5-69.2%) 56.2% (48.4-63.8%) 75-84 yrs. 57.7% (53.5-61.8%) 56.2% (52.3-60.1%) 55.5% (51.6-59.3%) 54.9% (50.8-58.9%) 56.3% (52.4-60.2%) 85-94 yrs. 46.4% (43.2-49.5%) 47.5% (44.4-50.6%) 50.9% (47.7-54.0%) 46.5% (43.6-49.5%) 46.4% (43.3-49.5%) 95+ yrs. 33.2% (28.2-38.5%) 28.7% (24.0-33.7%) 27.1% (22.4-32.3%) 28.0% (22.4-34.2%) 32.1% (26.4-38.3%) Sex Male 56.4% (52.1-60.6%) 58.6% (54.7-62.5%) 57.4% (53.3-61.3%) 56.2% (52.1-60.1%) 56.4% (52.4-60.4%) Female 45.9% (43.4-48.4%) 44.4% (41.9-46.8%) 46.1% (43.6-48.6%) 45.3% (42.8-47.8%) 45.3% (42.7-47.9%) Level of care at death None/Level I 66.3% (61.1-71.2%) 67.1% (62.5-71.6%) 65.8% (61.3-70.0%) 68.2% (63.7-72.3%) 64.3% (59.9-68.6%) Level II 54.3% (51.1-57.4%) 51.7% (48.5-54.8%) 52.7% (49.4-56.0%) 50.1% (46.8-53.4%) 52.1% (48.7-55.6%) Level III 33.3% (30.0-36.8%) 34.8% (31.6-38.2%) 35.7% (32.4-39.2%) 34.8% (31.5-38.2%) 35.2% (31.9-38.6%) Total 48.6% (46.4-50.8%) 48.4% (46.3-50.4%) 49.3% (47.2-51.5%) 48.3% (46.2-50.4%) 48.5% (46.4-50.7%)
Total (n=10,781) 59.6% (56.5-62.7%) 56.1% (54.3-57.8%) 47.5% (46.1-48.9%) 29.8% (27.5-32.2%) 57.0% (55.2-58.8%) 45.4% (44.3-46.5%) 66.3% (64.3-68.3%) 52.2% (50.7-53.7%) 34.8% (33.3-36.3%) 48.6% (47.7-49.6%)