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Chant ED, Ritchie CS, Orav EJ, Ganguli I. Healthcare contact days among older adults living with dementia. J Am Geriatr Soc 2024; 72:1476-1482. [PMID: 38263877 PMCID: PMC11090707 DOI: 10.1111/jgs.18744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/03/2023] [Accepted: 12/10/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND For older adults with dementia and their care partners, accessing health care outside the home involves substantial time, direct and indirect costs, and other burdens. While prior studies have estimated days spent by these individuals in or out of hospitals and nursing homes, ambulatory care burdens are likely substantial yet poorly understand. Therefore, we characterized "health care contact days"-days spent receiving ambulatory or institutional care-in this population. METHODS We used 2019 Medicare Current Beneficiary Survey data linked to claims for community-dwelling, ≥65-year-old adults with dementia in Traditional Medicare. We measured contact days including ambulatory days (with an office visit, test, imaging, procedure, or treatment) and institutional days (spent in an emergency department, hospital, skilled nursing facility, or hospice facility). We described variation and patterns in contact days. Using multivariable Poisson regression, we identified sociodemographic and clinical factors associated with contact days. RESULTS In weighted analyses, 887 older adults with dementia (weighted: 2.9 million) had mean (SD) 31.1 (33.7) total contact days/year, of which 21.7 (20.6) were ambulatory. Ten percent had ≥68 contact days in the year. One-third (34%) of ambulatory contact days involved multiple services. In multivariable models, receipt of more ambulatory contact days was associated with younger age (65-74 reference vs. -32.3% [95% CI: -42.2%, -20.7%] for 85+), higher income (>200% Federal Poverty Level [FPL] reference versus -16.6% [95% CI: -26.7%, -5.0%] for ≤200% FPL), and lack of functional impairment (reference versus -14.6% [95% CI: -23.7%, -4.4%]). Each additional chronic condition was associated with 8.2% (95% CI: 6.7%, 9.8%) more ambulatory contact days. CONCLUSIONS Older adults with dementia spent 31 days a year accessing care which was mostly ambulatory. These days varied widely by both clinical and sociodemographic factors. These results highlight the need to reduce patient burden through strategies such as reducing unneeded care, coordinating care, and shifting care to home settings through telemedicine and home care.
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Affiliation(s)
- Emma D. Chant
- Brigham and Women’s Hospital Division of General Internal Medicine and Primary Care, Boston, MA
| | - Christine S. Ritchie
- Harvard University, Boston, MA
- Mongan Institute Center for Aging and Serious Illness and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA
| | - E. John Orav
- Brigham and Women’s Hospital Division of General Internal Medicine and Primary Care, Boston, MA
- Harvard University, Boston, MA
| | - Ishani Ganguli
- Brigham and Women’s Hospital Division of General Internal Medicine and Primary Care, Boston, MA
- Harvard University, Boston, MA
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Mao Y, Li Y, McGarry B, Wang J, Temkin-Greener H. Home time and state regulations among Medicare beneficiaries in assisted living communities. J Am Geriatr Soc 2024; 72:742-752. [PMID: 38064278 PMCID: PMC10947931 DOI: 10.1111/jgs.18709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 10/06/2023] [Accepted: 11/12/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Home time is an important patient-centric quality metric, which has been largely unexamined among assisted living (AL) residents. Our objectives were to assess variation in home time among AL residents in the year following admission and to examine the associations with state regulations for direct care workers (DCW) training and staffing and for licensed nurse staffing. METHODS Medicare beneficiaries who entered AL communities in 2018 were identified, and their home time in the year following admission was measured. Home time was calculated as the percentage of time spent at home per day being alive. Resident characteristics and state regulations in DCW staffing, DCW training, and licensed staffing were measured. We used a multivariate linear regression model with AL-level fixed effects to estimate the relationship between person-level characteristics and home time. Linear regression models adjusting for resident characteristics were used to estimate the association between state regulations and residents' home time. RESULTS The study sample included 59,831 new Medicare beneficiary residents in 12,143 ALs. In the year following AL admission, residents spent 94% (standard deviation = 14.6) of their time at home. Several resident characteristics were associated with lower home time: Medicare-Medicaid dual eligibility, having more chronic conditions, and specific chronic conditions, for example, dementia. In states with greater regulatory specificity for DCW training and staffing, and lower specificity for licensed staffing, residents had longer adjusted home time. CONCLUSION/IMPLICATIONS Home time varied substantially among AL residents depending on resident characteristics and state-level regulatory specificity. AL residents eligible for Medicare and Medicaid had substantially shorter home time than the Medicare-only residents, largely due to longer time spent in nursing homes. State AL regulatory specificity for DCWs and licensed staff also impacted AL residents' home time. These findings may guide AL operators and state legislators in efforts to improve this important quality of life metric.
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Affiliation(s)
- Yunjiao Mao
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Yue Li
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Brian McGarry
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, University of Rochester School of Nursing, Rochester, New York, USA
| | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Ganguli I, Chant ED, Orav EJ, Mehrotra A, Ritchie CS. Health Care Contact Days Among Older Adults in Traditional Medicare : A Cross-Sectional Study. Ann Intern Med 2024; 177:125-133. [PMID: 38252944 PMCID: PMC10923005 DOI: 10.7326/m23-2331] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Days spent obtaining health care outside the home can represent not only access to needed care but also substantial time, effort, and cost, especially for older adults and their care partners. Yet, these "health care contact days" have not been characterized. OBJECTIVE To assess composition of, variation and patterns in, and factors associated with contact days among older adults. DESIGN Cross-sectional study. SETTING Nationally representative 2019 Medicare Current Beneficiary Survey data linked to claims. PARTICIPANTS Community-dwelling adults aged 65 years and older in traditional Medicare. MEASUREMENTS Ambulatory contact days (days with a primary care or specialty care office visit, test, imaging, procedure, or treatment) and total contact days (ambulatory days plus institutional days in a hospital, emergency department, skilled-nursing facility, or hospice facility); multivariable mixed-effects Poisson regression to identify patient factors associated with contact days. RESULTS In weighted results, 6619 older adults (weighted: 29 694 084) had means of 17.3 ambulatory contact days (SD, 22.1) and 20.7 total contact days (SD, 27.5) in the year; 11.1% had 50 or more total contact days. Older adults spent most contact days on ambulatory care, including primary care visits (mean [SD], 3.5 [5.0]), specialty care visits (5.7 [9.6]), tests (5.3 [7.2]), imaging (2.6 [3.9]), procedures (2.5 [6.4]), and treatments (5.7 [13.3]). Half of the test and imaging days were not on the same days as office visits (48.6% and 50.1%, respectively). Factors associated with more ambulatory contact days included younger age, female sex, White race, non-Hispanic ethnicity, higher income, higher educational attainment, urban residence, more chronic conditions, and care-seeking behaviors (for example, "go to the doctor…as soon as (I)…feel bad"). LIMITATION Study population limited to those in traditional Medicare. CONCLUSION On average, older adults spent 3 weeks in the year getting care outside the home. These contact days were mostly ambulatory and varied widely not only by number of chronic conditions but also by sociodemographic factors, geography, and care-seeking behaviors. These results show factors beyond clinical need that may drive overuse and underuse of contact days and opportunities to optimize this person-centered measure to reduce patient burdens, for example, via care coordination. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Ishani Ganguli
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston; and Harvard University, Boston, Massachusetts (I.G., E.J.O.)
| | - Emma D Chant
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts (E.D.C.)
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston; and Harvard University, Boston, Massachusetts (I.G., E.J.O.)
| | - Ateev Mehrotra
- Harvard University, Boston; and Beth Israel Deaconess Medical Center, Boston, Massachusetts (A.M.)
| | - Christine S Ritchie
- Mongan Institute Center for Aging and Serious Illness and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston; and Harvard University, Boston, Massachusetts (C.S.R.)
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Burke LG, Burke RC, Duggan CE, Figueroa JF, John Orav E, Marcantonio ER. Trends in healthy days at home for Medicare beneficiaries using the emergency department. J Am Geriatr Soc 2023; 71:3122-3133. [PMID: 37300394 PMCID: PMC10592590 DOI: 10.1111/jgs.18464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/04/2023] [Accepted: 05/08/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Older adults, particularly those with Alzheimer's Disease and Alzheimer's Disease Related Dementias (AD/ADRD), have high rates of emergency department (ED) visits and are at risk for poor outcomes. How best to measure quality of care for this population has been debated. Healthy Days at Home (HDAH) is a broad outcome measure reflecting mortality and time spent in facility-based healthcare settings versus home. We examined trends in 30-day HDAH for Medicare beneficiaries after visiting the ED and compared trends by AD/ADRD status. METHODS We identified all ED visits among a national 20% sample of Medicare beneficiaries ages 68 and older from 2012 to 2018. For each visit, we calculated 30-day HDAH by subtracting mortality days and days spent in facility-based healthcare settings within 30 days of an ED visit. We calculated adjusted rates of HDAH using linear regression, accounting for hospital random effects, visit diagnosis, and patient characteristics. We compared rates of HDAH among beneficiaries with and without AD/ADRD, including accounting for nursing home (NH) residency status. RESULTS We found fewer adjusted 30-day HDAH after ED visits among patients with AD/ADRD compared to those without AD/ADRD (21.6 vs. 23.0). This difference was driven by a greater number of mortality days, SNF days, and, to a lesser degree, hospital observation days, ED visits, and long-term hospital days. From 2012 to 2018, individuals living with AD/ADRD had fewer HDAH each year but a greater mean annual increase over time (p < 0.001 for the interaction between year and AD/ADRD status). Being a NH resident was associated with fewer adjusted 30-day HDAH for beneficiaries with and without AD/ADRD. CONCLUSIONS Beneficiaries with AD/ADRD had fewer HDAH following an ED visit but saw moderately greater increases in HDAH over time compared to those without AD/ADRD. This trend was visit driven by declining mortality and utilization of inpatient and post-acute care.
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Affiliation(s)
- Laura G. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ryan C. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ciara E. Duggan
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - E. John Orav
- Department of Medicine, Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Edward R. Marcantonio
- Divisions of General Medicine and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA, USA
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Shi SM, Olivieri-Mui B, Oh G, McCarthy E, Bean JF, Kim DH. Frailty and Time at Home After Post-Acute Care in Skilled Nursing Facilities. J Am Med Dir Assoc 2023; 24:997-1001.e2. [PMID: 37011886 PMCID: PMC10293028 DOI: 10.1016/j.jamda.2023.02.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVES To examine the association of a claims-based frailty index with time at home, defined as the number of days alive and spent out of hospital or skilled nursing facility (SNF). DESIGN Cohort Study. SETTING AND PARTICIPANTS A 5% Medicare random sample of fee-for-service beneficiaries, who had continuous part A and B enrollment in the prior 6 months, that were discharged from a short SNF admission in 2014‒2016. METHODS Frailty was measured with a validated claims-based frailty index (CFI) (range: 0‒1, higher scores indicating worse frailty) and categorized into nonfrail (CFI <0.25), mild frailty (CFI 0.25‒0.34), and moderate-to-severe frailty (CFI ≥0.35). We measured home time in the 6 months following SNF discharge (range: 0‒182 days with higher values representing more days at home and thus a better outcome). We used logistic regression to assess the association between frailty and short home time, defined as <173 days, adjusting for age, sex, race, region, a comorbidity index, clinical SNF admission characteristics in the Minimum Data Set, and SNF characteristics. RESULTS In our sample of 144,708 beneficiaries (mean age, 80.8 years, 64.9% female, 85.9% white) who were discharged to community after SNF stay, the mean CFI was 0.26 (standard deviation, 0.07). The mean home time was 165.6 (38.1) days in nonfrail, 154.4 (47.4) days in mild frailty, 145.0 (52.0) days in moderate-to-severe frailty group. After full model adjustments, moderate to severe frailty was associated with a 1.71 (95% CI 1.65‒1.78) higher odds of having short time at home in the 6 months following SNF discharge. CONCLUSION AND IMPLICATIONS Higher CFI is associated with short time at home in Medicare beneficiaries who are discharged to the community after post-acute SNF stay. Our results support the utility of CFI in identifying SNF patients who need additional resources and interventions to prevent health decline and poor quality of life.
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Affiliation(s)
- Sandra M Shi
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
| | - Brianne Olivieri-Mui
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA; Northeastern University, Boston, MA, USA
| | - Gahee Oh
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
| | - Ellen McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
| | - Jonathan F Bean
- New England GRECC, Veterans Affairs Boston Healthcare System, Boston, MA, USA; Department of PM&R, Harvard Medical School, Boston, MA, USA; Spaulding Rehabilitation Hospital, Boston, MA, USA
| | - Dae H Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA.
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Mao Y, Li Y, McGarry B, Wang J, Temkin-Greener H. Are online reviews of assisted living communities associated with patient-centered outcomes? J Am Geriatr Soc 2023; 71:1505-1514. [PMID: 36571798 PMCID: PMC10175089 DOI: 10.1111/jgs.18192] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 11/29/2022] [Accepted: 12/01/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Existing literature on online reviews of healthcare providers generally portrays online reviews as a useful way to disseminate information on quality. However, it remains unknown whether online reviews for assisted living (AL) communities reflect AL care quality. This study examined the association between AL online review ratings and residents' home time, a patient-centered outcome. METHODS Medicare beneficiaries who entered AL communities in 2018 were identified. The main outcome is resident home time in the year following AL admission, calculated as the percentage of time spent at home (i.e., not in institutional care setting) per day being alive. Additional outcomes are the percentage of time spent in emergency room, inpatient hospital, nursing home, and inpatient hospice. AL online Google reviews for 2013-2017 were linked to 2018-2019 Medicare data. AL average rating score (ranging 1-5) and rating status (no-rating, low-rating, and high-rating) were generated using Google reviews. Linear regression models and propensity score weighting were used to examine the association between online reviews and outcomes. The study sample included 59,831 residents in 12,143 ALs. RESULTS Residents were predominately older (average 81.2 years), non-Hispanic White (90.4%), and female (62.9%), with 17% being dually eligible for Medicare and Medicaid. From 2013 to 2017, ALs received an average rating of 4.1 on Google, with a standard deviation of 1.1. Each one-unit increase in the AL's average online rating was associated with an increase in residents' risk-adjusted home time by 0.33 percentage points (p < 0.001). Compared with residents in ALs without ratings, residents in high-rated ALs (average rating ≥4.4) had a 0.64 pp (p < 0.001) increase in home time. CONCLUSIONS Higher online rating scores were positively associated with residents' home time, while the absence of ratings was associated with reduced home time. Our results suggest that online reviews may be a quality signal with respect to home time.
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Affiliation(s)
- Yunjiao Mao
- Department of Public Health Sciences, University of Rochester School of Medicine & Dentistry, Rochester, NY
| | - Yue Li
- Department of Public Health Sciences, University of Rochester School of Medicine & Dentistry, Rochester, NY
| | - Brian McGarry
- Department of Public Health Sciences, University of Rochester School of Medicine & Dentistry, Rochester, NY
- Department of Medicine, University of Rochester School of Medicine & Dentistry, Rochester, NY
| | - Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, University of Rochester School of Nursing, Rochester, NY
| | - Helena Temkin-Greener
- Department of Public Health Sciences, University of Rochester School of Medicine & Dentistry, Rochester, NY
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Shen E, Eng S, Haupt EC, Wang SE, Mularski RA, Nguyen HQ. Assessing for disparities in days alive and at home in a palliative care population. J Am Geriatr Soc 2022. [PMID: 36571513 DOI: 10.1111/jgs.18211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/02/2022] [Accepted: 12/11/2022] [Indexed: 12/27/2022]
Affiliation(s)
- Ernest Shen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Sarah Eng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Eric C Haupt
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Susan E Wang
- West Los Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, California, USA
| | - Richard A Mularski
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Huong Q Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
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