Functional outcomes of posthospital care for stroke and hip fracture patients under medicare

BACKGROUND

Medicare's introduction of the Prospective Payment System for hospitals has led to tremendous growth in ways of providing posthospital care. Despite substantial differences in costs per episode of care, the type of posthospital care that produces the best results for specific types of patients is not clear. This study analyzed the outcomes of different types of posthospital care for a cohort of older Medicare patients (who had diagnoses associated with the use of a range of posthospital care modalities) for up to a year after hospital discharge.

METHODS

Medicare patients hospitalized with strokes and hip fractures were enrolled consecutively just before discharge from 52 hospitals in three cities in 1988-1989. These diagnosis-related groups were chosen because patients were discharged to all three major types of Medicare-supported posthospital care. Patients were interviewed in-person before discharge and again at 6 weeks, 6 months, and 1 year after discharge. The functional outcomes of posthospital care were evaluated by the instrumental variables estimation approach to correct for selection bias caused by nonrandom treatment assignment. The impacts of discharge locations on the functional outcomes were examined by one-way analyses of variance (ANOVA).

RESULTS

In general, the more disabled patients went to nursing homes and rehabilitation, but the overlap in distribution was sufficient to conduct the analyses. Stroke patients discharged to nursing homes had the highest mortality rate (P<.01). Stroke patients discharged to home health had the lowest rehospitalization rates (P<.05). Hip fracture discharged to home health care had the highest adjusted rehospitalization rate, whereas those discharged to nursing homes had the lowest adjusted rehospitalization rate (P<.05). For stroke patients, posthospital care in rehabilitation facilities or home health care was associated with significantly better functional improvement compared with stroke patients discharged elsewhere. However, functional outcomes deteriorated by 1 year posthospitalization among stroke patients who received their posthospital care at nursing homes or received no formal posthospital care. For hip fracture patients, all four types of posthospital care were associated with functional improvement, but patients discharged to rehabilitation facilities experienced the most functional improvement.

CONCLUSIONS

The choice of posthospital care can influence the course of Medicare patients. Careful attention should be paid to how hospital discharge decisions are made and to the financial incentives for different types of posthospital care provided under the current payment system. The current supply of nursing homes is not well suited to the demands of posthospital care.

Differences in valuation of functional status components among consumers and professionals in Europe and the United States

The ratings of the importance of functional status items among geriatric experts and consumers in Europe and the United States differed in many cases between experts and consumers in both countries; the differences were more frequent among the U.S. samples. The overall correlation between consumer and expert rankings was .82 for both groups. In general consumers, rated instrumental activities of daily living (IADL) items more highly, whereas the experts rated the most dysfunctional activities of daily living (ADL) items higher than did consumers. This study suggests the gap in doctor-patient communication. As function is increasingly used as a clinical outcome, agreement is needed on how to weight the components. The differences uncovered in this study suggest a need for more dialogue about what ends are truly sought by various parties.

The relationship between nursing staffing levels and nursing home outcomes

This study examined the effects of selected Minnesota nursing home attributes (size, ownership, noncompliance with a state correction order, and licensed and nonlicensed nursing hours) on specific outcomes (functional ability, discharge home, and death) for residents ages 65 and older, controlling for residents' age and previous functional ability. The functional outcome was operationalized by calculating the resident's Total Dependence Score (TDS), the total score on the assessment of eight activities of daily living (score range: 0-33). Ordinary least squares regression analysis was used to estimate the effects of facility attributes, admission TDS, and age on resident outcomes, and nonlinear probability analyses were used to estimate the effects of facility attributes, admission TDS, and age on the probability of death or discharge home. In the year after admission, licensed (but not nonlicensed) nursing homes were significantly related to improved functional ability, increased probability of discharge home, and decreased probability of death, but when limited to chronic residents, the role of professional nursing hours virtually disappears. Overall, the findings support greater use of licensed nurses in the nursing home setting.

Managed care as a vehicle for delivering more effective chronic care for older persons

Chronic illness is now the dominant feature of health care, and its impact will grow with the aging of the population. Managed care could provide an environment conducive to better care for chronically ill patients. A precondition for these activities is a shift in Medicare payment approaches to managed care organizations to recognize differences in risk. To improve care for the chronically ill, changes need to occur in two major areas: (1) The approach to chronic care needs to become more aggressive, with higher expectations about the benefits from care (even if measured by slowing the rate of decline), and (2) an information infrastructure is needed to help focus clinicians' attention on changes in patients' status. Some of these changes may eventually evolve spontaneously in managed care's search for more efficient ways of meeting its service obligations, but external forces, such as certification and federal mandates, could catalyze the transition.

Effects of post-hospital Medicare home health and informal care on patient functional status

OBJECTIVE

To examine the effect of post-hospital Medicare home health and informal care on the functional status of 755 Medicare beneficiaries six weeks after hospital discharge for treatment of stroke, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hip procedures, and hip fractures.

STUDY SETTING/DATA SOURCES

Consecutive patients enrolled in the study between March 1988 and February 1989 prior to discharge from one of 52 hospitals in three cities. Data sources included patient interviews, medical records, and the Medicare Automated Data Retrieval System (MADRS).

ANALYSIS

The effect of the two types of care on patients' subsequent functional status was estimated using a selectivity corrected least squares regression of functional status six weeks post-discharge on hours of informal care, Medicare home health expenditures, and patient prior functional and cognitive status.

DATA COLLECTION/EXTRACTION METHODS

Patients were interviewed before hospital discharge and six weeks later. The patient's primary caregiver was interviewed by telephone six weeks post-discharge. Patient data included demographic characteristics, illness severity, cognitive status, functional status at discharge and six weeks later, post-discharge expenditures for Medicare home health, and hours of informal care.

PRINCIPAL FINDINGS

More informal care after discharge was associated with greater patient functional impairment six weeks later. The amount of Medicare home health that patients used had a nonsignificant effect on subsequent functional status.

CONCLUSIONS

Post-acute home care may maintain the patient at home and compensate for functional limitations, rather than promote restoration of function. Future studies are needed to examine the effects of specific types of care, services, and providers as well as factors that mediate their effects on patient functional outcomes.

Variation in state spending for long-term care: factors associated with more balanced systems

Pressures to turn over responsibility for long-term care to the states will exacerbate the already sizable difference in such efforts. This article describes the nature of the interstate variation in the types and amounts of long-term care provided under Medicaid. The average Medicaid long-term care expenditure on persons sixty-five years and older varies from $2,720 in New York to $380 in Arizona. Likewise, payments for home and community-based services (HCBS) vary from $1,180 in New York to $29 in Mississippi. Only a modest portion (28 percent) of the variance in total long-term care expenditures appears to be related to differences in population characteristics, and even less (7 percent) appears to be related to differences in HCBS expenditures. When supply factors (e.g., nursing home beds) are added, the explained variance increases to 52 percent and 17 percent, respectively. Medicare replaces some--but not most--of the difference in Medicaid home and community-based services payments.

Outpatient geriatric evaluation and management

OBJECTIVE

To describe the development and operation of a practical model of outpatient geriatric evaluation and management (GEM) for high-risk, community-dwelling older adults.

PARTICIPANTS

Community-dwelling Medicare beneficiaries age 70 years and older who were medically stable but had a high probability of repeated admission to hospitals (P(ra) > .40) in the future (n = 248).

INTERVENTION

Outpatient GEM.

MEASUREMENTS

Demographic, clinical, and use-of-hospital characteristics of patients; nature and quantity of GEM services; satisfaction of patients and their established primary physicians.

RESULTS

At enrollment, the average patient was 78.7 years old, took 5.0 long-term prescription medications and was unable to perform 0.5 (of six) activities of daily living (ADL) and 1.4 (of seven) instrumental ADL. Many patients (71.3%) reported hospital days during the previous year. Each of three interdisciplinary teams (geriatrician, gerontological nurse practitioner, nurse and social worker) performed comprehensive assessments and then provided primary care and case management to a case load of 45 to 52 patients. On average, GEM required 6 months, during which patients visited the GEM clinic 7.4 times, had 10.4 active problems addressed, spoke to GEM staff members weekly by telephone, and were referred to two other providers. Most patients (94.4%) completed the GEM program; 66.7% completed advance directives. Satisfaction with GEM was high among the patients and their established primary physicians. The cost of the GEM personnel averaged about $1540 per patient treated.

CONCLUSIONS

This model of outpatient GEM provided 6 months of targeted intensive care at a reasonable cost. The satisfaction ratings of patients and their primary physicians were high.

Which outcomes matter in Alzheimer disease and who should define them?

The identification of salient outcomes depends on the conceptual map of the disease and its consequences. Early attention focuses on cognition. Cognitive losses can lead to behavioral problems, which may be exacerbated by treatment. Behavioral problems can create a need for supervision. Client functioning can require another form of supervision, cuing. Because Alzheimer disease affects families as much as patients, many outcomes are directed at measures of caregiver burden and stress. A therapeutic model of chronic care management, which aims at producing results at least as good as might be reasonably expected (i.e., slowing decline), creates a different mind set from a compensatory model of care, which seeks primarily to meet dependency needs. In the latter, good care is equivalent to meeting needs without incurring adverse events. Outcomes and locus of decision-making intersect around issues of quality of life. Assumptions about the ability of a patient with Alzheimer disease to express positive feelings or to indicate preferences for care need to be explored carefully. Although the use of agents or proxies may be necessary when making decisions about care, proxies serve poorly to convey information about another person's quality of life.

State variations in Medicare expenditures

OBJECTIVES

This study examined variations in Medicare expenditures across states.

METHODS

1992 data on average Medicare expenditures per enrollee, users of services per 1000 enrollees, service use per user, and payment per unit of service were compared across states for various services. Weighted least squares regression analysis was employed to examine total Medicare expenditures per enrollee by state.

RESULTS

Variation in Medicare expenditures across states is driven more by average number of service users per 1000 enrollees and average service units per user than by average payment per service unit. Medicare expenditures per enrollee by state are primarily a function of Medicare HMO penetration rate (P = .000), urban area (P = .001), hospital bed supply (P = .005), elderly mortality rate (P = .012), Medicare physician assignment rate (P = .026), percentage of primary care practitioners (P = .042), and interactions between urban elderly and percentage of primary care physicians (P = .005) and Black elderly and nursing home bed supply (P = .012).

CONCLUSIONS

Before sweeping Medicare cuts are undertaken or excessive reliance on managed care occurs, attention should be focused on the current disproportionate distribution of expenditures across states.

The substitutability of adult foster care for nursing home care in Oregon

OBJECTIVES

This study investigates the degree of substitutability of adult foster care for nursing home care in Oregon.

METHODS

Using three tests, the authors determined (1) the extent to which an additional adult foster care resident in a county reduces the number of nursing home residents in that county, (2) which characteristics of residents and facilities are important in sorting residents into either nursing homes or adult foster care facilities, and (3) the price elasticity of demand for adult foster care, using the county as the unit of observation.

RESULTS

It was found that for every additional foster care resident in a county, a nursing home loses 0.85 residents-almost a one-to-one substitution ratio.

CONCLUSIONS

Despite the high degree of substitutability, residents perceive important differences in the characteristics of the two forms of care. Indeed, private residents are, on average, willing to pay twice as much for nursing home care as for adult foster care, suggesting that these differences are important. Finally, private consumers are sensitive to price differences among adult foster care facilities. The implications for policy are discussed.

The relationship of patient satisfaction with care and clinical outcomes

OBJECTIVES

The authors examine the relationship between three dimensions of patient satisfaction (quality of care, hospital care, and physician time) and two ways of looking at outcomes: absolute (status at 6 months after surgery) and relative (difference between baseline and follow-up status).

METHODS

A total of 2,116 patients undergoing cholecystectomy were interviewed before surgery and again at 6 months. The baseline interview addressed health status (general functioning and specific symptoms) and risk factors. The follow-up interview included health status and a series of satisfaction questions. Outcomes included both overall health status and specific symptoms. Potential confounding factors, in addition to baseline status, such as demographics, casemix, and procedure type, were accounted for in the analysis.

RESULTS

Each of the outcomes was related significantly to each of the satisfaction scales; however, the relative outcomes were related more strongly to satisfaction than were the absolute versions. Although the regression coefficients were highly significant, none of the outcomes measures accounted for more than 8% of the explained variance in the several satisfaction scores.

CONCLUSIONS

Although outcomes and satisfaction are related, more goes into satisfaction than just outcomes. When determining their satisfaction with the care they have received, patients are more likely to focus on their present state of health than to consider the extent of improvement they have enjoyed.

Does scoliosis have a psychological impact and does gender make a difference?

STUDY DESIGN

A population-based case-control study, we identified adolescents with and without scoliosis in Minnesota who were 12 through 18 years of age. Matched control subjects were randomly selected from school children who did not have scoliosis or any other condition. Information on scoliosis was obtained by a self-administered questionnaire, the Adolescent Health Survey. Collected on more than 75,000 school age adolescents, with established validity and reliability, a secondary analysis of adolescents with scoliosis was performed as compared with a normative peer group.

OBJECTIVE

To describe and characterize the psychosocial impact of scoliosis on the areas of peer relations, body image, and health-compromising behavior, such as suicidal thought and alcohol consumption.

SUMMARY OF BACKGROUND DATA

The impact of adolescent idiopathic scoliosis has not been assessed using generic health status measures appropriate for adolescents. Previous studies have concentrated on the health status of adults by measuring work status, marriage status, and other adult measures. The purpose of this study was to study the health status of patients with adolescent idiopathic scoliosis, using the Adolescent Health Survey, a generic health status measure with established validity and reliability.

METHODS

Body image, peer relations, social and high-risk behavior, and comparative health were assessed to determine if scoliosis was an independent risk factor and to determine if scoliosis was associated with these psychosocial issues.

RESULTS

Six hundred eighty-five cases of scoliosis were identified from the 34,706 adolescents. The prevalence was 1.97%. Of the 685 adolescents with scoliosis and their control subjects, the adjusted odds ratio for having suicidal thought among adolescent with scoliosis, compared to adolescents without scoliosis, was 1.40 (P value of 0.04) after adjustment for race, gender, socioeconomic status, and age. The adjusted odds ratio for having feelings about poor body development among adolescents with scoliosis was 1.82 (P value 0.001) compared with adolescents without scoliosis after adjustment for race, gender, socioeconomic status, and age. Scoliosis was an independent risk factor for suicidal thought, worry and concern over body development, and peer interactions after adjustment.

CONCLUSION

Scoliosis is a significant risk factor for psychosocial issues and health-compromising behavior. Gender differences exist in male and female adolescents with scoliosis.

Improving outcomes in rehabilitation. A call to arms (and legs)

In rehabilitation, assessment of outcomes requires refinement of existing measurement and analysis tools. A suitable taxonomy of outcomes, risk factors, and treatment modalities must be developed to reflect the field's complexity and the multiplicity of care providers. The goal of outcomes studies is to distinguish the effects of treatment from improvement resulting from the natural course of illness. Outcomes researchers must adjust for casemix and be alert to possible selection effects. A common set of outcome measures is needed to measure disability. Those currently in use reflect both nursing home and rehabilitation care. They rely on provider information and measure patients' performance, but they do not record patients' perceptions of important components of outcomes. Current techniques for describing treatment are inadequate. Outcomes assessment must include adjustment for prognostic factors and must be measured against baseline information at the onset of treatment. Although patients' perception of care is recognized as important to outcomes assessment, patients should also play a central role in decision-making about care and in weighting the importance of the various outcomes. In an era of managed care, the major challenge for rehabilitation care is to demonstrate its cost-effectiveness. Clear and precise analysis of the salient issues and a dynamic model of outcomes measurement will facilitate this goal and will permit incorporation of new learning in this field.

Variations in the performance of hip fracture procedures

OBJECTIVES

Hip replacement is the preferred treatment for displaced femoral neck fractures, whereas other less expensive procedures are preferred for nondisplaced fractures. The authors determined whether there was geographic variation in the use of hip replacement to treat displaced and nondisplaced fractures.

METHODS

The authors studied 332 patients, age 65 years or older, hospitalized with a femoral neck fracture in three cities.

RESULTS

The population was 55% over age 80, 80% female, and lived in Houston (17%), Pittsburgh (29%), and Minneapolis (54%). Rates of hip replacement varied by city (Houston-84%, Pittsburgh-77%, Minneapolis-63%; P = 0.002), with great variability among patients with nondisplaced fractures (Houston-88%, Pittsburgh-77%, and Minneapolis-56%; P = 0.0001), and no variation among those with displaced fractures (P = 0.72). Other factors associated with hip replacement are history of hip fracture (P = 0.003) and cerebrovascular disease (P < or = 0.10), APACHE II-APS score (P = 0.09), and impacted fracture (P = 0.001). Sociodemographic and functional status (perceived health; activities of daily living and instrumental activities of daily living dependencies) were not associated with hip replacement (P > 0.10). In a logistic model controlling for prior history, APACHE II-APS, and fracture characteristics, city remained a significant predictor of hip replacement (P < 0.001).

CONCLUSIONS

Despite an absence of evidence supporting its appropriateness and a much higher cost, hip replacement is used to treat nondisplaced fractures much more frequently in Houston and Pittsburgh than in Minneapolis.

Outcomes for older men and women with congestive heart failure

OBJECTIVES

To describe and compare outcomes for men and women discharged alive following a hospitalization for congestive heart failure (CHF).

DESIGN

Prospective cohort study.

PARTICIPANTS

A total of 519 patients, aged > or = 65, who were discharged alive after a hospitalization for CHF (DRG = 127).

MEASUREMENTS

Outcomes (Activities of Daily Living (ADLs), shortness of breath when walking, perceived health, living situation, rehospitalization, and mortality) were measured at 3 times (6 weeks, 6 months, and 1 year) post-discharge.

RESULTS

The 205 men were, on average, younger (77 +/- 7 vs 80 +/- 8, P < .001), wealthier (46% vs 21% earned > or = $10,000, P < .001), and more often married (50% vs 19%, P < .001). Men were more likely than women to have a previous history of CHF (71% vs 63%, P = .052). Men also had higher 1-year mortality than women (48% vs 35%, P = .009), even after adjusting for age, comorbidity, physiological severity (APACHE II APS and RAND discharge instability), radiological evidence of CHF, prior ADLs, walking ability, living situation, and perceived health. Men and women survivors at 1-year had similar and substantial impairment for all non-fatal outcomes considered (all P values > or = .489). Their adjusted mean ADL scores were consistent with complete dependence on one essential activity (range 0-6 dependencies); 35% were short of breath walking less than 1 block; 62% had fair or poor perceived health; 32% received some formal care; and 46% were rehospitalized within 1 year of discharge.

CONCLUSIONS

Men with CHF have a higher mortality than women with CHF. Men and women who survive have similar and substantial impairment for all non-fatal outcomes (ADLs, shortness of breath upon walking, perceived health, living situation, and rehospitalization).

Neuropsychological and psychological functioning in chronic fatigue syndrome

Although patients with chronic fatigue syndrome (CFS) typically present subjective complaints of cognitive and psychological difficulties, studies to date have provided mixed objective support for the existence of specific cognitive deficits. The present study was designed to examine differences in performance between individuals diagnosed with CFS and matched controls with respect to sustained attention, processing efficiency, learning, and memory. Subjects included 17 patients meeting Centers for Disease Control research criteria for CFS and 17 control subjects. Subjects were administered six measures assessing attention, memory, and word-finding ability and two measures assessing psychological distress. For the most part, the two groups did not differ on measures of neurocognitive functioning. Significant group differences were found on a single measure of attention and incidental memory. However, CFS patients differed markedly from controls with respect to reported psychological distress. The results support previous findings of notable levels of psychological distress among CFS patients. They also suggest the need for alternative research paradigms to assess the cognitive abilities of CFS patients.

Consumer and professional ratings of the importance of functional status components

As the population ages and chronic disease becomes the more dominant form of illness, measures of functional loss and disability assume greater importance in the assessment of both quality of life and the cost-effectiveness of care. The authors studied the responses of consumers and health care professionals regarding the impact on dependency of various levels of disability. Striking differences in perception were noted, raising concerns about the ability of those providing care to assume that the recipients share their values about what is important. This study makes clear the need for more research on functional outcome measurements that incorporate the values of consumers.

Improving hospital discharge planning for elderly patients

Hospital discharge planning has become increasingly important in an era of prospective payment and managed care. Given the changes in tasks, decisions, and environments involved, it is important to identify how to move such planning from an art to an empirically based decisionmaking process. The authors use a decision-sciences framework to review the state-of-the-art of hospital discharge planning and to suggest methods for improvement.

Decreasing disability in the 21st century: the future effects of controlling six fatal and nonfatal conditions

OBJECTIVES

This study assessed the effects of reducing fatal and nonfatal health conditions on the number of functionally limited older Americans in the coming decades.

METHODS

Data from the 1990 census and the Longitudinal Study of Aging were used to project the number of functionally limited older Americans from 2001 to 2049, assuming 1% biennial reductions in five conditions that shorten life expectancy (coronary artery disease, stroke, cancer, diabetes, and confusion) and one condition that decreases functional ability (arthritis).

RESULTS

Decreasing the prevalence of arthritis by 1% every 2 years would lead to a much greater reduction in functional limitation between 2001 and 2049 (4 million person-years) than would decreasing any of the other conditions by the same amount. Decreases in two fatal conditions (cancer and coronary artery disease) would lead to increases in functional limitation (0.9 and 0.1 million person-years, respectively).

CONCLUSIONS

Advances against common nonfatal disabling conditions would be more effective than advances against fatal conditions in blunting the large increase in the functionally limited older population anticipated in the 21st century.

Do rehabilitative nursing homes improve the outcomes of care?

OBJECTIVES

To compare the differences in outcomes of Medicare patients discharged from hospital to two types of nursing homes, rehabilitative and regular, and to rehabilitative facilities.

DESIGN

Criteria for distinguishing rehabilitative nursing homes (RNHs) from ordinary nursing homes (NH), based on staffing criteria, were developed by an expert panel and validated on a national sample of nursing homes. Those criteria that significantly discriminated the two types of NHs were then applied to a sample of nursing homes from a study of the outcomes of care for more than 2500 Medicare patients to classify the nursing homes in which patients were discharged. Actual discharge outcomes were compared with optimal outcomes based of predictive equations for different types of treatment (ordinary NH care, RNH care, and formal rehabilitative care).

PARTICIPANTS

Medicare patients with strokes an hip fractures discharged from 52 hospitals in three cities.

MEASUREMENTS

A disability scale that weights components of ADL measures was used as the primary outcome indicator. Nursing homes were classified as rehabilitative on the basis of the extent of staffing in rehabilitative areas.

RESULTS

Patients discharged to various types of care varied on several parameters. After adjusting for these differences, stroke patients fared better when treated in rehabilitative facilities; there was no substantial benefit for RNH care over NH care. Healthier hip fracture patients who received RNH care fared better, but functional change for sicker hip fracture patients was not different among the three groups.

CONCLUSIONS

The study suggests that at least a preliminary distinction among NHs can be made on the basis of staffing patterns and that the benefits of the additional staffing may vary with the problem under consideration. More work is needed to establish just what sorts of patients are most likely to benefit from the higher level of NH care.