Individual Socioeconomic Factors Have a Greater Impact on End-of-Life Care Outcomes Than Regional Factors.

Background: End-of-life (EoL) care provided to Americans in urban and rural settings is distinct in terms of both available and delivered services. However, much less is known about which geographic, demographic, and health indicators are associated with disparities in EoL care and how individual versus regional characteristics influence quality of care (QoC). Objective: This study aimed to assess how regionality, rurality, and individual socioeconomic factors are associated with QoC in the last month of life (LML). Design: Nationally representative cross-sectional study using the proxy-completed LML questionnaire as part of the National Health and Aging Trends Study (NHATS). The data were linked at the zip code level to geographic and economic indicators. Settings/Subjects: A total of 2778 NHATS enrollees who died from 2012 to 2020. Measurements: Measurements included population density, socioeconomic indicators, health factors, and health outcomes. The primary independent variable was proxy-reported QoC during the LML (excellent vs. not excellent). Results: In our sample, 52.1% (n = 1447) reported not excellent care and 47.9% (n = 1331) reported excellent care. These populations varied in their demographic and socioeconomic characteristics. After accounting for survey weighting and design, decedents in the top (odds ratio [OR]: 1.58; 95% confidence interval [CI]: 1.08-2.32) income quartile had significantly greater odds of receiving excellent care than decedents in the bottom quartile. Decedents in zip codes with top quartile health outcome metrics had significantly greater odds of receiving excellent care (OR: 1.64; 95% CI: 1.17-2.29) than decedents in zip codes with bottom quartile health outcomes. County rurality index and county health factors were not correlated with QoC in the LML. Conclusions: High QoC at the EoL may be more associated with individual socioeconomic factors than regional indicators, including degrees of rurality. Clinicians should strive to recognize the interplay of individual characteristics and regional indicators to provide more personalized care.

Paid Care for People with Functional Impairment and Serious Illness: Results from the Health and Retirement Study.

BACKGROUND: Paid caregivers (e.g., home health aides) care for individuals living at home with functional impairment and serious illnesses (health conditions with high risk of mortality that impact function and quality of life). OBJECTIVE: To characterize those who receive paid care and identify factors associated with receipt of paid care in the context of serious illness and socioeconomic status. DESIGN: Retrospective cohort study. PARTICIPANTS: Community-dwelling participants ≥ 65 years enrolled in the Health and Retirement Study (HRS) between 1998 and 2018 with new-onset functional impairment (e.g., bathing, dressing) and linked fee-for-service Medicare claims (n = 2521). MAIN MEASURES: Dementia was identified using HRS responses and non-dementia serious illness (e.g., advanced cancer, end-stage renal disease) was identified using Medicare claims. Paid care support was identified using HRS survey report of paid help with functional tasks. KEY RESULTS: While about 27% of the sample received paid care, those with both dementia and non-dementia serious illnesses in addition to functional impairment received the most paid care (41.7% received ≥ 40 h of paid care per week). In multivariable models, those with Medicaid were more likely to receive any paid care (p < 0.001), but those in the highest income quartile received more hours of paid care (p = 0.05) when paid care was present. Those with non-dementia serious illness were more likely to receive any paid care (p < 0.001), but those with dementia received more hours of care (p < 0.001) when paid care was present. CONCLUSIONS: Paid caregivers play a significant role in meeting the care needs of those with functional impairment and serious illness and high paid care hours are common among those with dementia in particular. Future work should explore how paid caregivers can collaborate with families and healthcare teams to improve the health and well-being of the seriously ill throughout the income spectrum.