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2019 HSR&D/QUERI National Conference Abstract

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1160 — SITE OF DEATH AND HOSPICE USE AT DEATH AMONG VETERANS DYING IN VA'S HOME BASED PRIMARY CARE

Lead/Presenter: Orna Intrator,  Canandaigua VAMC
All Authors: Intrator O (Geriatrics & Extended Care Data Analysis Center (GECDAC), Canandaigua VAMC and University of Rochester), Li, Jiejin (GECDAC, Canandaigua VAMC and University of Rochester), Davis, D (VACO Geriatrics & Extended Care) Karuza, J (Canandaigua VAMC and University of Rochester) Gillespie, S (Canandaigua VAMC and University of Rochester)

Objectives:
Home Based Primary Care (HBPC) is provided across the VA by interdisciplinary team-managed primary care aiming to maintain Veterans at home till death. This study explored disparities in site of death and hospice use at death among Veterans dying in HBPC.

Methods:
Fiscal year (FY) 2016 VHA, Medicare utilization and enrollment data, nursing home resident assessments and HBPC Masterfile were used to create a Residential History File (RHF) for Veterans in HBPC within 30 days of death. RHFs track the location and type of utilization daily and thus identify site (home, NH, hospital) and hospice use on the day of death. Veterans' race, residential rurality and living conditions were modeled adjusting for physical function, comorbidities, and number of days in HBPC. Multinomial logistic regression models of death location and logistic regression of hospice use clustered at HBPC sites were estimated and used to obtain marginal effects.

Results:
In FY2016 61.8% decedents died at home while 25.0% died in hospitals and 12.3% died in NHs. Hospice at death was recorded for 53.7%, 43.2% and 63.6% of Veterans who died at home, in hospitals and in NHs, respectively. Majority of Veterans were white (84%), 20% lived alone, 33% lived in rural/ highly rural settings; 49.5% were in HBPC < 30 days, and 78% had Activity of Daily Living (ADL) impairments. Death at home was less likely among Veterans who were African American (AA) (-3.7%) or lived alone (-5.8%). Death at home with hospice was more likely among Veterans who were married (6.9%), lived in rural/ highly rural settings (5.0%) or had ADLs (5.1%), but was less likely among Veterans who were AA (-7.3%), non-White/AA (-8.2%), had no caregiver (-7.5%), or who lived alone (-8.1%).

Implications:
Veterans in HBPC were highly likely to die at home. Racial differences in likelihood of death at home mirror other disparities and may reflect unrecorded preferences. Higher likelihood of death at home with hospice in rural settings may reflect HBPC initiatives. HBPC appears to have difficulty providing quality care to Veterans who live alone.

Impacts:
Analyses of site of death can provide insights to programs caring for Veterans at end of life.