As a part of a larger study of black and white nursing home patients in Alabama, it is learned that as many as 44% of the deaths occur within a month after admission. Short-lived patients are necessarily under-represented in cross-sectional studies, giving rise to the myth that only a small proportion of the elderly end their lives in nursing homes. In fact, cross-sectional enumerations are heavily biased against those whose lives in institutions are short or who are moved to hospitals for their final medical crisis. The evidence suggests that some, if not many, families may institutionalize their older members only under great duress.
The Four Percent Fallacy Some Further Evidence and Policy Implications 1 Harold J. Wershow, DSW2
ferent manner than the work of Kastenbaum and Candy (1973), which corroborates their thesis.
Though only 4% of the aged are generally assumed to be resident in Nursing Homes (NH) at any one time, a much larger proportion of old people will spend some of their last days as Nursing Home Patients (NHP). Kastenbaum and Candy (1973) have noted that, in Metropolitan Detroit, 23% (not 4%) of the aged deaths occur in NH and other extended care facilities; 85% of those deaths take place in NH. Therefore, many more than 4% of the aged must spend longer or shorter periods of time in NH. An additional large but currently unknown number of NHP are transferred from NH to general hospitals for either terminal care or a critical episode of an acute or chronic illness. Some of those who recover or who fail to die with all deliberate speed (Claser & Strauss, 1968) are moved from the hospital to the same or another NH. This process may inflate the statistics of NH admissions, but does not change the statistics of numbers of those resident in such institutions at any one time. We present here additional evidence gathered in a somewhat dif-
Scope of the Study
Two students undertook an independent studies project, investigating the last 100 deaths that occurred in "black" NH in Jefferson County, Alabama (the county in which Birmingham is located). We found the results sufficiently startling to extend the study to 3 additional NH, 1 "black" and 2 "white." There are, in Alabama, 7 proprietary black skilled NH, 5 of them in Jefferson County. These are all relatively small (30-75 beds), all but 1 owned and run by a black family or individual, with an exclusively black administration and staff. There are, in the state, roughly 150 white skilled proprietary NH, some family owned, others chain-owned and operated. All are white administered, with racially mixed staffs. All 5 homes whose patient deaths are studied herein are in Jefferson County, in Birmingham or its suburbs. The white homes were somewhat larger than the black, having about 100 beds each. At the time of this study, 2 of the 3 "predominantly black" NH (the euphemism currently employed) had never had a white
1. This paper is one part of a larger pilot study of "Certain Characteristics of Black and White Proprietary Nursing Home Patients in Birmingham and Rural Alabama," funded by AoA Grant 93 p - 5734/4 - 01, USDHEW. We gratefully acknowledge the support of that agency and the assistance of Diane Chambliss, Caroline Lyons, and Lyn Cutcliffe, who have gathered the data. 2. Professor of Sociology, University College, Univ. of Alabama, Birmingham 35294.
52
The Gerontologist
least for these — the patients most likely to die soon after admission, who provide a quick rate of turnover of NH bed usage) and under which circumstances patients are moved from NH to hospital in acute crises and when approaching death. We suspect that the crucial variables in moving NH patients to hospitals are: (1) the NH policy in calling physicians' attention to its moribund patients; (2) the physicians' readiness to transfer NHP to hospital; (3) the extent to which family and friends of NHP trust the NH competence in dealing with the critically ill and either permit the NHP to remain in the NH or pressure physicians to admit NHP to hospitals.
patient; of the "predominantly white" NH patients, 14% were black. This is a fairly recent development. The civil rights enforcement unit in the State Health Department has only recently been able to enforce vigorously racial integration in NH. For this reason, we can assume that the proportion of white patients who died in the black NH to be negligible and the proportion of black patients who died in white NH to be somewhat larger, but that the 14% figure cited is considerably higher than the proportion of black patients in those white homes for the entire period studied. We were unable to check other records which would confirm the race of the patients. The administrators and proprietors were uncertain about their obligation to protect the confidentiality of their records and uneasy about allowing us to identify individual patients sufficiently so that we might seek out death certificates from the Bureau of Vital Statistics. We, therefore, decided to disregard the small errors that might arise if we considered all patient deaths that occur in black NH to be deaths of black and vice versa. We were unable to meet our goal of 500 deaths in the five NH. One black NH required the records for another purpose in the midst of our study; we have, therefore, recorded 200 white and 260 black deaths. An additional qualification of the aim "to investigate the last 100 deaths" in each NH is that a number of records were missing, being used by the physician, various third-party payees, etc. We had no reason to believe that these missing records introduced any systematic biases into the study.
In addition, the extent to which NHP die shortly after transfer from hospital is determined largely by the definition of "maximum hospital benefit" (MHB) by Medicare and Medicaid. As the cost of public support of aged patients continues to rise, definitions of MHB will become more stringent. If Medicare and Medicaid refuse to pay hospital bills, patients are forced to leave the hospital, even though their life expectancy may be measured in hours, rather than days or weeks; in this study, 3% of the deaths occurred within 24 hours after admission! It is not easy to trace the movement of patients in and out of NH. Since Medicare and Medicaid are, understandably, reluctant to continue payment to a NH while the NHP is in a hospital, it is a frequent practice for NH to "discharge" patients who are transferred to hospitals. As was noted by Kastenbaum and Candy (1973), if NHP survive and if the NH from which they came has no empty beds when they are ready to leave the hospital, they may be moved to another NH. It is also not uncommon for hospital records to list patients as "discharged home" with the unofficial and unnoted understanding that the family will place him/her in a NH at the earliest opportunity. Though each NH is supposed to have a cooperative working relationship with a hospital to ensure continuity of patient care, such continuity does not exist. We have seen nothing that gives us any reason to believe that such agreements are more than pieces of paper drawn up for the sole purpose of satisfying Medicare and Medicaid certification requirements. Indeed, it is not possible that they be anything more, as long as NHP retain their own physicians, each of whom arranges
Lack of Policy on Transfers
Our first observation was the great variation among NH in the time period necessary to gather 100 consecutive deaths. It was necessary to go back 30 mo. to secure 100 deaths in a 175-bed NH. A 50-bed NH, which should have had 100 deaths in 45 mo. (if its death rate was the same as the first home), actually required 54 mo., or an additional one-third more time. A larger 100-bed home required no more time to amass 100 deaths than the 75 bed home cited above. It quickly became apparent that there is no uniform policy to determine which patients shall be released to NH from hospitals (which seems to be the modal route for admission — at Vol.16, No. 1,Pt. 1,1976
53
for hospital admission for his own patients to whichever hospitals grant him staff privileges. The great pressures to discharge patients as soon as MHB is achieved prevents hospitals from building constructive relationships with particular NH. The situation may be different in rural areas in which the few area physicians affiliated with the one local hospital also serve the few NH in the vicinity of the hospital. In such situations, written agreements are unnecessary; in urban situations they are necessarily meaningless under prevailing conditions. Deaths in Nursing Homes
An enormous proportion of these deaths (44%) occurred within 30 days of admission. Detailed data, disaggregated by age and sex, are available upon request to the author. If all diseases of the heart and blood vessels are aggregated (mostly strokes and heart attacks, but including aneurisms, subdural hemorrhages and other abnormalities of circulation), these account for 55% of the black and 46% of the white deaths; chronic brain syndrome (under its various names of cerebral arteriosclerosis, senility, etc.) is listed as the primary diagnosis in another 18% of both races. Cancer accounts for 11% of the black and 2 1 % of the white deaths. More precise categorization is not possible because, whatever standardization of nomenclature is required in death certificates, nomenclature employed in NH medical records is highly idiosyncratic. Indeed, for older persons suffering from several interrelated severe chronic illnesses, it is often no more than an academic exercise to decide which was the major cause of death. While black females in this study, as in others, are the longest lived group, taken as a whole, some interesting findings emerge if deaths are disaggregated by age (^80 versus 80+) race and sex (all comparisons are by chi-square, with p equal to .05 as the measure of significance): those black and white females
The Four Percent Fallacy Some Further Evidence and Policy Implications 1 Harold J. Wershow, DSW2
ferent manner than the work of Kastenbaum and Candy (1973), which corroborates their thesis.
Though only 4% of the aged are generally assumed to be resident in Nursing Homes (NH) at any one time, a much larger proportion of old people will spend some of their last days as Nursing Home Patients (NHP). Kastenbaum and Candy (1973) have noted that, in Metropolitan Detroit, 23% (not 4%) of the aged deaths occur in NH and other extended care facilities; 85% of those deaths take place in NH. Therefore, many more than 4% of the aged must spend longer or shorter periods of time in NH. An additional large but currently unknown number of NHP are transferred from NH to general hospitals for either terminal care or a critical episode of an acute or chronic illness. Some of those who recover or who fail to die with all deliberate speed (Claser & Strauss, 1968) are moved from the hospital to the same or another NH. This process may inflate the statistics of NH admissions, but does not change the statistics of numbers of those resident in such institutions at any one time. We present here additional evidence gathered in a somewhat dif-
Scope of the Study
Two students undertook an independent studies project, investigating the last 100 deaths that occurred in "black" NH in Jefferson County, Alabama (the county in which Birmingham is located). We found the results sufficiently startling to extend the study to 3 additional NH, 1 "black" and 2 "white." There are, in Alabama, 7 proprietary black skilled NH, 5 of them in Jefferson County. These are all relatively small (30-75 beds), all but 1 owned and run by a black family or individual, with an exclusively black administration and staff. There are, in the state, roughly 150 white skilled proprietary NH, some family owned, others chain-owned and operated. All are white administered, with racially mixed staffs. All 5 homes whose patient deaths are studied herein are in Jefferson County, in Birmingham or its suburbs. The white homes were somewhat larger than the black, having about 100 beds each. At the time of this study, 2 of the 3 "predominantly black" NH (the euphemism currently employed) had never had a white
1. This paper is one part of a larger pilot study of "Certain Characteristics of Black and White Proprietary Nursing Home Patients in Birmingham and Rural Alabama," funded by AoA Grant 93 p - 5734/4 - 01, USDHEW. We gratefully acknowledge the support of that agency and the assistance of Diane Chambliss, Caroline Lyons, and Lyn Cutcliffe, who have gathered the data. 2. Professor of Sociology, University College, Univ. of Alabama, Birmingham 35294.
52
The Gerontologist
least for these — the patients most likely to die soon after admission, who provide a quick rate of turnover of NH bed usage) and under which circumstances patients are moved from NH to hospital in acute crises and when approaching death. We suspect that the crucial variables in moving NH patients to hospitals are: (1) the NH policy in calling physicians' attention to its moribund patients; (2) the physicians' readiness to transfer NHP to hospital; (3) the extent to which family and friends of NHP trust the NH competence in dealing with the critically ill and either permit the NHP to remain in the NH or pressure physicians to admit NHP to hospitals.
patient; of the "predominantly white" NH patients, 14% were black. This is a fairly recent development. The civil rights enforcement unit in the State Health Department has only recently been able to enforce vigorously racial integration in NH. For this reason, we can assume that the proportion of white patients who died in the black NH to be negligible and the proportion of black patients who died in white NH to be somewhat larger, but that the 14% figure cited is considerably higher than the proportion of black patients in those white homes for the entire period studied. We were unable to check other records which would confirm the race of the patients. The administrators and proprietors were uncertain about their obligation to protect the confidentiality of their records and uneasy about allowing us to identify individual patients sufficiently so that we might seek out death certificates from the Bureau of Vital Statistics. We, therefore, decided to disregard the small errors that might arise if we considered all patient deaths that occur in black NH to be deaths of black and vice versa. We were unable to meet our goal of 500 deaths in the five NH. One black NH required the records for another purpose in the midst of our study; we have, therefore, recorded 200 white and 260 black deaths. An additional qualification of the aim "to investigate the last 100 deaths" in each NH is that a number of records were missing, being used by the physician, various third-party payees, etc. We had no reason to believe that these missing records introduced any systematic biases into the study.
In addition, the extent to which NHP die shortly after transfer from hospital is determined largely by the definition of "maximum hospital benefit" (MHB) by Medicare and Medicaid. As the cost of public support of aged patients continues to rise, definitions of MHB will become more stringent. If Medicare and Medicaid refuse to pay hospital bills, patients are forced to leave the hospital, even though their life expectancy may be measured in hours, rather than days or weeks; in this study, 3% of the deaths occurred within 24 hours after admission! It is not easy to trace the movement of patients in and out of NH. Since Medicare and Medicaid are, understandably, reluctant to continue payment to a NH while the NHP is in a hospital, it is a frequent practice for NH to "discharge" patients who are transferred to hospitals. As was noted by Kastenbaum and Candy (1973), if NHP survive and if the NH from which they came has no empty beds when they are ready to leave the hospital, they may be moved to another NH. It is also not uncommon for hospital records to list patients as "discharged home" with the unofficial and unnoted understanding that the family will place him/her in a NH at the earliest opportunity. Though each NH is supposed to have a cooperative working relationship with a hospital to ensure continuity of patient care, such continuity does not exist. We have seen nothing that gives us any reason to believe that such agreements are more than pieces of paper drawn up for the sole purpose of satisfying Medicare and Medicaid certification requirements. Indeed, it is not possible that they be anything more, as long as NHP retain their own physicians, each of whom arranges
Lack of Policy on Transfers
Our first observation was the great variation among NH in the time period necessary to gather 100 consecutive deaths. It was necessary to go back 30 mo. to secure 100 deaths in a 175-bed NH. A 50-bed NH, which should have had 100 deaths in 45 mo. (if its death rate was the same as the first home), actually required 54 mo., or an additional one-third more time. A larger 100-bed home required no more time to amass 100 deaths than the 75 bed home cited above. It quickly became apparent that there is no uniform policy to determine which patients shall be released to NH from hospitals (which seems to be the modal route for admission — at Vol.16, No. 1,Pt. 1,1976
53
for hospital admission for his own patients to whichever hospitals grant him staff privileges. The great pressures to discharge patients as soon as MHB is achieved prevents hospitals from building constructive relationships with particular NH. The situation may be different in rural areas in which the few area physicians affiliated with the one local hospital also serve the few NH in the vicinity of the hospital. In such situations, written agreements are unnecessary; in urban situations they are necessarily meaningless under prevailing conditions. Deaths in Nursing Homes
An enormous proportion of these deaths (44%) occurred within 30 days of admission. Detailed data, disaggregated by age and sex, are available upon request to the author. If all diseases of the heart and blood vessels are aggregated (mostly strokes and heart attacks, but including aneurisms, subdural hemorrhages and other abnormalities of circulation), these account for 55% of the black and 46% of the white deaths; chronic brain syndrome (under its various names of cerebral arteriosclerosis, senility, etc.) is listed as the primary diagnosis in another 18% of both races. Cancer accounts for 11% of the black and 2 1 % of the white deaths. More precise categorization is not possible because, whatever standardization of nomenclature is required in death certificates, nomenclature employed in NH medical records is highly idiosyncratic. Indeed, for older persons suffering from several interrelated severe chronic illnesses, it is often no more than an academic exercise to decide which was the major cause of death. While black females in this study, as in others, are the longest lived group, taken as a whole, some interesting findings emerge if deaths are disaggregated by age (^80 versus 80+) race and sex (all comparisons are by chi-square, with p equal to .05 as the measure of significance): those black and white females
