Resident level characteristics
Resident characteristics are presented in Table 1. The study sample included 595,152 unique elderly individuals, 48% long-stay (n = 285,888) and 52% short-stay residents (n = 309,264). These individuals resided in 6,241 NHs across the nation. Except for the presence of hospice unit within NH facilities, all other variables were significantly different across the long and short-stay groups (p<.0001). The residents were predominantly female (61%), non-Hispanic White (85%), and died between the ages of 86-90 (24%). The average age at death was 84 years (SD ± 8.35). Nearly half (49%) were in oldest age group, age 86 and older. Little over half (52%) reported their marital status as widowed. The proportion of those widowed were higher among long-stay residents (58%) than in short-stay (46%) residents (p<.0001). The most common chronic conditions were CHF (50%) and CKD (48%). Although the total proportion of sample residents who suffered from Alzheimer’s disease were 29%, the proportion was much higher among long-stay residents than short-stay residents (41% vs. 17%, respectively, p<0.001). The proportion of cancer patients was higher among short-stay residents than long-stay residents (19% vs. 8%, respectively, p<.0001). Over half (57%) of all residents died in NH, and this was more common among long-stay residents than short-stay residents (76% vs 41% respectively, p<.0001).
State POLST program characteristics
The majority of states (59%) had a POLST program with developing maturity status, followed by endorsed (35%), non-conforming (5%) and mature (1%). Nearly all (95%) of sample residents (i.e., 95% of all long-stay and 96% of all short-stay residents) were from the states where the POLST program had developing or higher maturity status.
The contextual variables are presented in Table 2. Most NHs were for-profit status (72%) and chain affiliated (57%). More than half (59%) of NHs were equipped with 100-199 beds, with an average occupancy rate of 84% (± 13.60). The was on average 0.74 hours per resident day for registered nurses (SD ± 0.43), 0.84 hours per resident day for licensed practical nurses (SD ± 0.35), and 2.16 hours per resident day for certified nursing assistant (SD ± 0.65). Twenty two percent of all NHs were equipped with Alzheimer’s unit; only 1% had a hospice unit (1%). NHs were mainly located in the South (36%) and in metropolitan areas (81%). The average proportion of elderly population per county was 10% (SD ± 3.27), and the median household income per county was $53,334.54 (SD ± 13,957.46)
Impact of POLST maturity status on NH death
Table 3 shows the result of multivariable logistic regression. The odds of dying in NHs were 20% higher in states that had mature POLST programs, compared to states where the POLST program was non-conforming (OR: 1.20, 95% CI 1.02-1.43). Residents in a state where the POLST program had developing status had 12% (OR: 1.12, 95% CI 1.02-1.24) increased odds of dying in NHs compared to residents in states where the POLST program was non-conforming. Endorsed POLST status showed 11% increase in NH death, but lacked significance (OR: 1.09, 95% CI 98-1.21). There was no difference for short-stay residents.
Predictors of NH death by Stay Type
In long-stay residents, older age groups had progressively higher likelihood of dying in NHs (ORs: 1.14-4.02). This association was similar in the short-stay group (ORs 1.04-2.88). Although odds of dying in NHs were not statistically different between the reference group (65-70 years) and the second youngest age group (71-75 years); all other age groups had progressively higher odds of dying in NHs (OR: 1.04, 1.19, 1.35, 1.63, 1.91, 2.23 for age group 76-80, 81-85, 86-90, 91-95, 96-100, 101-110, respectively).
In both long and short-stay residents, individuals who were never married, divorced, separated, or widowed had higher likelihood of dying in NHs than married individuals (ORs: 1.10-1.57). In a long-stay group, separated marital status was the strongest predictor of NH deaths (OR: 1.27, 95% CI 1.14-1.40) compared to the married status. For the short-stay residents, never been married was the strongest predictor of NH deaths (OR: 1.52, 95% CI 1.47-1.57).
In the long-stay residents, compared to White race, all other race groups (i.e., African American, American Indian, Asian, Hispanic, Native Hawaiian/ Pacific Islander, 2 or more race) had lower odds of dying in NHs (ORs: 0.66-0.71). In the short-stay residents, those who were Asian or multiple races had higher odds of dying in NHs (OR 1.22, 1.35, 95% CI 1.07-1.38, 1.15-1.58, respectively).
COPD increased likelihood of death in NHs compared to those who did not have COPD (OR: 1.49, 95% CI 1.45-1.53 long-stay; OR: 1.20, 95% CI 1.18-1.23 short-stay). Alzheimer’s disease also increased likelihood of dying in NHs (OR: 1.49, 95% CI 1.44-1.54; OR: 1.45, 95% CI 1.42-1.48, respectively). An inverse relationship was noted in likelihood of dying in NHs for the NH residents suffering from cancer (OR 0.83, 95% CI: 0.81-0.86 for long stay; OR: 1.18, 95% CI 1.15-1.20 for short stay).
Facility characteristics associated with NH death were the presence of Alzheimer’s unit (OR: 1.15, 95% CI 1.11-1.20 for long-stay; OR 1.16, 95% 95% CI 1.08-1.21 for short-stay), and the smaller NH facilities with less than 50 beds (OR: 1.16, 95% CI: 1.09, 1.24 for long-stay; OR1.12, 95% CI: 1.10-1.28 for short-stay), compared to NHs with 50-99 beds.