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Do‐Not‐Resuscitate and Do‐Not‐Hospitalize Directives of Persons Admitted to Skilled Nursing Facilities Under the Medicare Benefit
Cari R. Levy, Ronald H. Fish, Andrew M. Kramer. Journal of the American Geriatrics Society, 2005-11-08
Topic: Risk, prevention and care in population studies
Thirty-two percent of residents had DNR directives, whereas less than 2% had DNH directives. Factors associated with having a DNR or DNH directive at the resident level included older age, cognitive impairment, functional dependence, and Caucasian ethnicity. African-American, Hispanic, Asian, and North American Native residents were all significantly less likely than Caucasian residents to have DNR (adjusted odds ratio (OR)=0.35, 0.51, 0.61, and 0.62, respectively) or DNH (adjusted OR=0.26, 0.41, 0.43, and 0.67, respectively) directives. In contrast, residents in rural and government facilities were more likely to have DNR or DNH directives. After controlling for resident and facility characteristics, significant variation between states existed in the use of DNR and DNH directives. Ethnic minorities are less likely to have DNR and DNH directives even after controlling for disease status, demographic, facility, and geographic characteristics. Wide variation in the likelihood of having DNR and DNH directives between states suggests a need for better-standardized methods for eliciting the care preferences of residents admitted to SNFs under the Medicare benefit.
Key findings
- Thirty-two percent of residents had DNR directives, whereas less than 2% had DNH directives.
- Factors associated with having a DNR or DNH directive at the resident level included older age, cognitive impairment, functional dependence, and Caucasian ethnicity.
- African-American, Hispanic, Asian, and North American Native residents were all significantly less likely than Caucasian residents to have DNR (adjusted odds ratio (OR)=0.35, 0.51, 0.61, and 0.62, respectively) or DNH (adjusted OR=0.26, 0.41, 0.43, and 0.67, respectively) directives.
- In contrast, residents in rural and government facilities were more likely to have DNR or DNH directives.
- After controlling for resident and facility characteristics, significant variation between states existed in the use of DNR and DNH directives.
Why it matters
This study found that ethnic minority residents in skilled nursing facilities were less likely to have do-not-resuscitate or do-not-hospitalize directives than Caucasian residents. It addresses end-of-life care preferences, not the treatment, cure, or prevention of Alzheimer's disease.
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Study details
- Study designcohort study
- Participants1,962,742
- Effect sizeOR=0.26
- Evidence strengthModerate
How this study scored 57/100
Published in a peer-reviewed journal, and it is a cohort study following people over time. Scored zero for randomised / blinded because the record does not state it.
| Component | Points | Why |
|---|---|---|
| Journal tier | 7 / 10 | Tier 3 — peer-reviewed journal (Journal of the American Geriatrics Society) |
| Journal's citation record | 3 / 4 | Journal of the American Geriatrics Society: journal h-index 344 (OpenAlex, 2026-10-29) |
| Study design | 7 / 12 | A cohort study following people over time |
| Strength of evidence | 3 / 5 | Rated “moderate” in our summary |
| Peer-review validation | 10 / 10 | Peer-reviewed. Published as an article in a named peer-reviewed journal. |
| How recent | 1 / 5 | 2005 — older than 20 years, still counted |
| Sample size | 4 / 4 | 1,962,742 participants |
| Effect reported | 3 / 3 | Effect reported with a statistic (interval, p-value, ratio or similar) |
| Studied in people | 3 / 3 | Studied in people (participant count stated) |
| Randomised / blinded | 0 / 2 | No randomisation or blinding stated — scores zero (not stated in the record — scored 0) |
| Times cited | 4 / 7 | Cited 62 times (OpenAlex, 2026-10-10) |
| Citations per year | 1 / 5 | 2.7 citations a year over 23 year(s) since 2005 |
| Impact for its field and year | 3 / 6 | Cited 4.9× the average for papers of its field and year (OpenAlex FWCI) |
| Cited by studies here | 1 / 6 | Cited by 1 other studies in this library |
| Still being cited | 1 / 4 | Cited 4 times in 2024–2026 (2026 still in progress; OpenAlex) |
| Senior author's track record | 2 / 4 | Last-listed author Andrew M. Kramer: h-index 49 (OpenAlex, whole career) |
| Institution's track record | 1 / 3 | University of Colorado Denver: institution h-index 907 (OpenAlex) |
| Multi-centre collaboration | 1 / 3 | OpenAlex lists 2 institution(s) in 1 country |
| Indexed in PubMed | 2 / 2 | Indexed in PubMed (PMID 16398888) |
| Free to read | 0 / 2 | Behind a paywall — scores zero |
| Total | 57 / 100 | — |
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Read the original
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Cite this study APA, Vancouver, BibTeX · download .bib or .ris
Built from the record alzhub holds for this paper, not looked up. Volume, issue and page numbers are not held in the record. Check the citation against the original before you use it.
APA 7th
Levy, C. R., Fish, R. H., & Kramer, A. M. (2005). Do‐Not‐Resuscitate and Do‐Not‐Hospitalize Directives of Persons Admitted to Skilled Nursing Facilities Under the Medicare Benefit. Journal of the American Geriatrics Society. https://doi.org/10.1111/j.1532-5415.2005.00523.x
Vancouver
Levy CR, Fish RH, Kramer AM. Do‐Not‐Resuscitate and Do‐Not‐Hospitalize Directives of Persons Admitted to Skilled Nursing Facilities Under the Medicare Benefit. Journal of the American Geriatrics Society. 2005. doi:10.1111/j.1532-5415.2005.00523.x. PMID: 16398888.
BibTeX
@article{levy2005-16398888,
author = {Levy, Cari R. and Fish, Ronald H. and Kramer, Andrew M.},
title = {{Do‐Not‐Resuscitate and Do‐Not‐Hospitalize Directives of Persons Admitted to Skilled Nursing Facilities Under the Medicare Benefit}},
journal = {Journal of the American Geriatrics Society},
year = {2005},
doi = {10.1111/j.1532-5415.2005.00523.x},
pmid = {16398888},
url = {https://doi.org/10.1111/j.1532-5415.2005.00523.x}
}
Later studies that cite this one
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