ABSTRACT
Individuals with Alzheimer’s disease and related dementias (ADRD) often face hospitalizations and other
burdensome interventions at end of life that could be avoided with better preemptive medical care –
specifically, early recognition and treatment of acute illness, improved advance care planning and palliative
care, and availability of resources to manage acute conditions in the outpatient setting. Nurse practitioners and
physician assistants, collectively known as advanced practice clinicians (APCs), are playing an increasingly
important role in the medical management of older adults in both nursing home and community settings, yet
little is known about how these clinicians influence end of life outcomes for people with ADRD under traditional
fee-for-service Medicare. Additionally, APC scope of practice is governed by state regulations which vary
considerably and it is unknown how these regulations impact the provision of end of life care to people with
ADRD, particularly those living in rural or medically underserved areas. The long-term goal of this research is
to develop evidence that will inform workforce planning and policy efforts to provide high quality care to people
with ADRD at end of life. Our central hypotheses are that APCs provide services to vulnerable sub-populations
of people with ADRD who may otherwise have poor access to quality end of life care; and that the involvement
of APCs in care reduces the likelihood of being exposed to burdensome interventions at end of life. To test
these hypotheses, we propose a cross-sectional study using 2015-2018 Medicare claims and administrative
data with the following specific aims: (1) To describe population and state regulatory characteristics associated
with people with ADRD receiving care from APCs at end of life; (2) To evaluate whether APC care is
associated with acute care utilization in the last month of life, death in a hospital, hospice utilization, and
feeding tube placement for people with ADRD; and (3) To evaluate whether the effects of APC care on end of
life outcomes vary across states with different scope of practice regulations. This will be the first study to
examine the impact of APCs on end of life outcomes for individuals with ADRD, or for any population of
Medicare beneficiaries. Findings from this study will inform staffing composition for nursing homes, physician
practices, and other healthcare organizations that care for people with ADRD; provide guidance to state
policymakers who design APC scope of practice regulations; and inform workforce planning, training, and
recruitment efforts for schools and healthcare organizations.