Disability After Hospitalization Too Common in Seniors

Miriam E. Tucker

April 07, 2015

NATIONAL HARBOR, Maryland — One of the largest contributors to medical costs incurred by senior citizens is functional impairment after hospitalization, new research shows, yet Medicare does not measure it.

Severe functional impairment — defined as a person needing help in at least two activities of daily living — is among the most expensive conditions in the year after hospitalization. In fact, it could cost Medicare billions of dollars annually, according to data presented here at the Society of Hospital Medicine 2015 Annual Meeting.

The condition is an "overlooked but critical variable in the changing story of outcomes for patients," said Ryan Greysen, MD, from the University of California, San Francisco, who presented the study findings.

In another recent study, Dr Greysen and colleagues showed that severe functional impairment is a predictor of 30-day all-cause readmission in Medicare patients (JAMA Intern Med. Published online February 2, 2015).

"The big takeaway is that there's this really important predictor of outcomes — and now, it turns out, costs — that we're not even measuring. It's completely off our radar," he told Medscape Medical News.

Ironically, he added, Medicare requires functional assessment for reimbursement in acute rehabilitation and nursing-home settings, but not in hospitals or skilled-nursing facilities.

"So it's not that Medicare lacks the apparatus to collect these data, they're just not doing it at hospitals yet," he explained. "At a policy level, we think that Medicare ought to start telling hospitals, 'we want functional data on your patients admitted for acute care'."

There's this really important predictor of outcomes — and now, it turns out, costs — that we're not even measuring.

"It's surprising," said session moderator Kathlyn Fletcher, MD, from the Medical College of Wisconsin in Milwaukee. "When you think about it, you realize it's actually intuitive, but you don't think about it the way you think about other comorbidities."

In hospital practice, functional impairment is typically handled by calling in physical or occupational therapy consults.

Our ability to deal with the condition "depends on how good those services are, and how early we can get them involved," said Dr Fletcher. It is likely that many hospitals have the necessary tools, but "whether they're routinely implemented to get the best results is a different question," she said.

A Costly Condition

Dr Greysen's team used data from the Health and Retirement Study, a nationally representative longitudinal analysis of community-dwelling adults older than 50 years. About 20,000 individuals participate in the study every 2 years, and 85% of participants allow their data to be linked to their Medicare claims, so the work reflects current demographics, Dr Greysen reported.

The investigators analyzed 7608 Medicare beneficiaries and their 21,565 hospital admissions from 2000 to 2010.

The mean age of the cohort was 78.5 years, and 58% of the participants were women, 85% were white, 49% married or partnered, and 67% had attained at least a high school education.

In the previous year, 86% of the participants had been hospitalized. They had a mean of 5.7 comorbidities each, as measured on the 30-item Elixhauser index (Med Care. 1998;36:8-27).

Most, 65%, had no functional impairment in activities of daily living — such as toileting, transferring from one location to another, eating, and bathing — 18% had difficulty with one activity, 8% required help with one activity, and 9% required help with two activities.

The primary study outcome — total cost of care in the year after hospital discharge — was assessed through Medicare claims and adjusted for inflation. The investigators also adjusted for age, sex, race, marital status, income, wealth, education, number of Elixhauser comorbidities, and the number of hospitalizations in the previous year.

There was a linear relation between functional level and cost at 1 year, which ranged from $21,263 for those with no functional impairment to $39,705 for those with severe impairment requiring help with at least two activities of daily living.

To come up with a rough system-level estimate of the cost for 1 year of care after hospital discharge, the team used estimates from the Dartmouth Atlas of Health Care for patients 65 years and older. They calculated that there is a $221 billion difference in cost between patients with no impairment and those with severe impairment ($243 billion vs $464 billion).

"Functional impairment has remained stable since 2000 to 2010, but costs have risen, so if anything this is an underestimate," Dr Greysen said.

Surprisingly, the proportion of costs attributed to repeat hospitalizations in the year after the index hospitalization was slightly lower in patients with severe impairment than in those with no impairment, although not significantly so (49% vs 53%).

Skilled-nursing facility care accounted for more of the cost for those with severe impairment than with no impairment (20% vs 12%), as did home healthcare (12% vs 7%), and outpatient care accounted for slightly less of the cost (9% vs 13%).

Of the 15 most expensive comorbid conditions on the Elixhauser index, requiring help for at least two activities of daily living ranks fourth, behind lymphoma, renal failure, and metastatic cancer, but ahead of conditions such as paralysis, coagulopathy, complicated diabetes, and congestive heart failure. Requiring help for one activity of daily living ranks fourteenth.

Although these data are preliminary, severe functional impairment is likely to continue to rank high on the list, Dr Greysen told Medscape Medical News.

"Right now it's in the top 5. Maybe it will get higher or lower, but we've had the suspicion for a while that this is one of the top 5, or at least top 10, most important drivers of outcomes and costs and anything that we care about," he said.

Fixing the Dysfunction

Dr Fletcher told Medscape Medical News that she agrees that functional impairment is a condition unto itself: "That's a good way to think of it."

This is relevant to medicine as a whole. "I would go so far as to say that this is an issue for any hospitalized patient, whether medical or surgical. Certainly if patients make it to the ICU, this is an even bigger issue, because the functional impairments are sure to be growing at that point," she said. "But what do we do with this information? How can we use this to plan better?"

Dr Fletcher said that she will likely use the data in her hospitalist practice to convince her teams how significant a burden this is. "I think I'll probably try to pay attention to this more in my own history-taking," she added.

Dr Greysen said he would like to see all hospitals routinely measure activities of daily living in inpatients 65 years and older, "regardless of national or Medicare policy. We should do this because it matters to our patients," he told Medscape Medical News.

There are several scales available. Dr Greysen said he uses the classic Katz scale (Urol Nurs. 2007;27:93-94), but Medicare actually uses two different scales for acute rehabilitation and nursing homes.

"Each one captures slightly different domains, but they're related," he explained. "I would advise picking any measure of functional status and use it consistently, at least in patients over 65, and we'll be doing better than we are now."

"There's big money at stake," he added. "If clinicians could identify the people who are at risk, I think we could definitely save some money and improve care. How much, we're still trying to sort out."

Dr Greysen and Dr Fletcher have disclosed no relevant financial relationships.

Society of Hospital Medicine 2015 Annual Meeting. Presented March 31, 2015.


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