Background In the last 6 months of life many older adults will experience a hospitalization followed by a transfer to a skilled nursing facility (SNF) for additional care. We sought to examine patterns of SNF use in the last 6 months of life. Methods We used the Health and Retirement Study, a longitudinal survey of older adults, linked to Medicare claims (1994-2007). We determined the number of individuals age 65 and older at death who used the SNF benefit in the last 6 months of life. We report demographic, social, and clinical correlates of SNF use. We examined the relationship between place of death and hospice use for those living in nursing homes and community prior to the last 6 months of life. Results The mean age at death of the 5,163 subjects was 83 (54% female; 23% nursing home residents). We found 30.5% used the SNF benefit in the last 6 months of life, and 9.2% died enrolled on the SNF benefit. Use of the SNF benefit was greater among patients who were: 85 and older, had a high school education, did not have cancer, were nursing home residents, used home health services, and were expected to die (all p<0.01). Of community dwellers who used the SNF benefit 42.5% died in a nursing home, 10.7% died at home, 38.8% died in the hospital, and 8% died elsewhere. In contrast, of community dwellers that did not use the SNF benefit 5.3% died in a nursing home, 40.6% died at home, 44.3% died in the hospital, and 9.8% died elsewhere. Conclusion Nearly one-third of older adults receive care in a SNF in the last 6 months of life under the Medicare SNF benefit, and 1 out of 11 elders will die on the SNF benefit. Palliative care services should be incorporated into SNF-level care.

Objective To determine if diabetes clinical standards consider increased hypoglycemia risk in vulnerable patients. Data Sources MEDLINE, the National Guidelines Clearinghouse, the National Quality Measures Clearinghouse, and supplemental sources. Study Design Systematic review of clinical standards (guidelines, quality metrics, or pay-for-performance programs) for glycemic control in adult diabetes patients. The primary outcome was discussion of increased risk for hypoglycemia in vulnerable populations. Data Collection/Extraction Methods Manuscripts identified were abstracted by two independent reviewers using prespecified inclusion/exclusion criteria and a standardized abstraction form. Principal Findings We screened 1166 titles, and reviewed 220 manuscripts in full text. 44 guidelines, 17 quality metrics, and 8 pay-for-performance programs were included. 5 (11%) guidelines, and no quality metrics or pay-for-performance programs met the primary outcome. Conclusions Clinical standards do not substantively incorporate evidence about increased risk for hypoglycemia in vulnerable populations.

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