Family Structure and Location Shape End-of-Life Acute Care Use in Nursing Homes

OBJECTIVES: Gaps in end-of-life (EOL) care for nursing home (NH) residents persist, with notable rural/urban differences and important variability in family availability across settings. We examined how rural vs urban settings and first-degree family structure relate to EOL acute care utilization among residents who died in NHs. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: A total of 42,806 individuals aged 65+ who died in rural (n = 10,440) or urban (n = 32,366) NHs, linked via population pedigree to 122,655 first-degree family members (spouses, children, and siblings). METHODS: We used logistic and negative binomial regression models to estimate inpatient hospitalization and emergency department (ED) use in the last 1 and 6 months of life. Primary predictors were location and family structure (measured as the presence of child(ren), spouse, spouse with child(ren), no child(ren), no spouse), and we assessed whether family structure modified rural-urban differences in EOL care. RESULTS: Most residents were female, non-Hispanic White, and died in urban NHs. Overall, 26% experienced at least 1 hospitalization in the last month of life and 52% in the last 6 months; 11% had an ED visit in the last month and 28% in the last 6 months. Rural residents had higher ED utilization at both 1 and 6 months and higher hospitalization at 1 month only. Family structure-particularly the presence of a spouse or a spouse with child(ren)-was associated with higher hospitalization but had minimal influence on ED visits. Moderation of family structure by location was observed with lower hospitalization rates among residents with child(ren) only in rural facilities. CONCLUSIONS AND IMPLICATIONS: EOL acute care use among NH residents varies by location and family structure. Tailoring EOL care to family and geographic context and leveraging telehealth for palliative care and family engagement may improve care and reduce potentially burdensome utilization, implicating future research on additional familial and contextual factors.