Healthcare costs for legally adjudicated elder mistreatment victims in comparison to non-mistreated older adults

BACKGROUND

Elder mistreatment (EM) is associated with adverse health outcomes and healthcare utilization patterns that differ from other older adults. However, the association of EM with healthcare costs has not been examined. Our goal was to compare healthcare costs between legally adjudicated EM victims and controls.

METHODS

We used Medicare insurance claims to examine healthcare costs of EM victims in the 2 years surrounding initial mistreatment identification in comparison to matched controls. We adjusted costs using the Centers for Medicare and Medicaid Services Hierarchical Condition Categories (CMS-HCC) risk score.

RESULTS

We examined healthcare costs in 114 individuals who experienced EM and 410 matched controls. Total Medicare Parts A and B healthcare costs were similar between cases and controls in the 12 months prior to initial EM detection ($11,673 vs. $11,402, p = 0.92), but cases had significantly higher total healthcare costs during the 12 months after initial mistreatment identification ($15,927 vs. $10,805, p = 0.04). Adjusting for CMS-HCC scores, cases had, in the 12 months after initial EM identification, $5084 of additional total healthcare costs (95% confidence interval [$92, $10,077], p = 0.046) and $5817 of additional acute/subacute/post-acute costs (95% confidence interval [$1271, $10,362], p = 0.012) compared with controls. The significantly higher total costs and acute/sub-acute/post-acute costs among EM victims in the post-year were concentrated in the 120 days after EM detection.

CONCLUSIONS

Older adults experiencing EM had substantially higher total costs during the 12 months after mistreatment identification, driven by an increase in acute/sub-acute/post-acute costs and focused on the period immediately after initial EM detection.

Emergency Department and Hospital Utilization Among Older Adults Before and After Identification of Elder Mistreatment

Importance

Elder mistreatment is common and has serious health consequences. Little is known, however, about patterns of health care utilization among older adults experiencing elder mistreatment.

Objective

To examine emergency department (ED) and hospital utilization of older adults experiencing elder mistreatment in the period surrounding initial mistreatment identification compared with other older adults.

Design, Setting, and Participants

This retrospective case-control study used Medicare insurance claims to examine older adults experiencing elder mistreatment initially identified between January 1, 2003, and December 31, 2012, and control participants matched on age, sex, race and ethnicity, and zip code. Statistical analysis was performed in April 2022.

Main Outcomes and Measures

We used multiple measures of ED and hospital utilization patterns (eg, new and return visits, frequency, urgency, and hospitalizations) in the 12 months before and after mistreatment identification. Data were adjusted using US Centers for Medicare and Medicaid Services Hierarchical Condition Categories risk scores. Chi-squared tests and conditional logistic regression models were used for data analyses.

Results

This study included 114 case patients and 410 control participants. Their median age was 72 years (IQR, 68-78 years), and 340 (64.9%) were women. Race and ethnicity were reported as racial or ethnic minority (114 [21.8%]), White (408 [77.9%]), or unknown (2 [0.4%]). During the 24 months surrounding identification of elder mistreatment, older adults experiencing mistreatment were more likely to have had an ED visit (77 [67.5%] vs 179 [43.7%]; adjusted odds ratio [AOR], 2.95 [95% CI, 1.78-4.91]; P < .001) and a hospitalization (44 [38.6%] vs 108 [26.3%]; AOR, 1.90 [95% CI, 1.13-3.21]; P = .02) compared with other older adults. In addition, multiple ED visits, at least 1 ED visit for injury, visits to multiple EDs, high-frequency ED use, return ED visits within 7 days, ED visits for low-urgency issues, multiple hospitalizations, at least 1 hospitalization for injury, hospitalization at multiple hospitals, and hospitalization for ambulatory care sensitive conditions were substantially more likely for individuals experiencing elder mistreatment. The rate of ED and hospital utilization for older adults experiencing elder mistreatment was much higher in the 12 months after identification than before, leading to more pronounced differences between case patients and control participants in postidentification utilization. During the 12 months after identification of elder mistreatment, older adults experiencing mistreatment were particularly more likely to have had high-frequency ED use (12 [10.5%] vs 8 [2.0%]; AOR, 8.23 [95% CI, 2.56-26.49]; P < .001) and to have visited the ED for low-urgency issues (12 [10.5%] vs 8 [2.0%]; AOR, 7.33 [95% CI, 2.54-21.18]; P < .001).

Conclusions and Relevance

In this case-control study of health care utilization, older adults experiencing mistreatment used EDs and hospitals more frequently and with different patterns during the period surrounding mistreatment identification than other older adults. Additional research is needed to better characterize these patterns, which may be helpful in informing early identification, intervention, and prevention of elder mistreatment.

Emergency Department Utilization Patterns Among Physical Elder Abuse Victims in Comparison to Other Older Adults

Background: Physical elder abuse is common and has serious health consequences. Little is known, however, about the patterns of health care utilization among these victims, including whether opportunities may exist for earlier identification and intervention. Our goal was to describe Emergency Department (ED) utilization known physical elder abuse victims compared with non-victims. Methods: We used Medicare insurance claims to examine ED utilization patterns among a well-characterized cohort of 139 known physical elder abuse victims in the year before abuse was identified and compared this to control subjects matched on age, sex, race, and residential zip code. Results: Physical elder abuse victims were significantly more likely than control subjects to visit the ED (47.5% vs. 35.9%, p=0.01) during the year before identification and to have at least one visit for an injury-related complaint (14.4% vs. 8.3%, p=0.03). Victims were also more likely to have multiple visits (18.7% vs. 14.6%, p=0.24), visit multiple EDs (7.9% vs. 6.7%, p=0.63), or be high frequency utilizers (≥4 visits, 3.6% vs. 2.7%, p=0.58), but differences did not reach statistical significance. The most common diagnoses in ED visits among victims were: open wound of knee/ankle, exacerbation of chronic bronchitis, pneumonia, and chest pain. Conclusion: This work provides preliminary evidence that physical elder abuse victims use the ED more frequently and potentially have different patterns of utilization than other older adults. We plan to further characterize these different patterns to potentially to use them to develop tools for earlier identification.

Identifying patterns of health care utilisation among physical elder abuse victims using Medicare data and legally adjudicated cases: protocol for case-control study using data linkage and machine learning

INTRODUCTION

Physical elder abuse is common and has serious health consequences but is under-recognised and under-reported. As assessment by healthcare providers may represent the only contact outside family for many older adults, clinicians have a unique opportunity to identify suspected abuse and initiate intervention. Preliminary research suggests elder abuse victims may have different patterns of healthcare utilisation than other older adults, with increased rates of emergency department use, hospitalisation and nursing home placement. Little is known, however, about the patterns of this increased utilisation and associated costs. To help fill this gap, we describe here the protocol for a study exploring patterns of healthcare utilisation and associated costs for known physical elder abuse victims compared with non-victims.

METHODS AND ANALYSIS

We hypothesise that various aspects of healthcare utilisation are differentially affected by physical elder abuse victimisation, increasing ED/hospital utilisation and reducing outpatient/primary care utilisation. We will obtain Medicare claims data for a series of well-characterised, legally adjudicated cases of physical elder abuse to examine victims' healthcare utilisation before and after the date of abuse detection. We will also compare these physical elder abuse victims to a matched comparison group of non-victimised older adults using Medicare claims. We will use machine learning approaches to extend our ability to identify patterns suggestive of potential physical elder abuse exposure. Describing unique patterns and associated costs of healthcare utilisation among elder abuse victims may improve the ability of healthcare providers to identify and, ultimately, intervene and prevent victimisation.

ETHICS AND DISSEMINATION

This project has been reviewed and approved by the Weill Cornell Medicine Institutional Review Board, protocol #1807019417, with initial approval on 1 August 2018. We aim to disseminate our results in peer-reviewed journals at national and international conferences and among interested patient groups and the public.

Substance Use Is Common in Elder Abuse Cases: Qualitative Findings From a Multi-Disciplinary Team

Elder abuse is mistreatment of an older adult by a caregiver or another person in a position with an expectation of trust. Adversely affecting as many as 10% of community-dwelling older adults in the US, it may include physical abuse, sexual abuse, psychological abuse, financial exploitation and neglect. Mental illness and substance use by caregivers, family members and victims themselves have been described as risk factors for multiple forms of elder abuse in prior cross-sectional analyses but the impact on these cases is poorly understood. To explore this association we conducted a focus group using a semi-structured format involving an inter-disciplinary group of elder abuse professionals that are part of the New York City Elder Abuse Center enhanced multi-disciplinary team (EMDT) in Staten Island, New York. Focus group participants reported that opioid, cocaine, cannabis and alcohol use is common among perpetrators of elder abuse, especially in cases of financial mistreatment, verbal and physical abuse. Other potential consequences included eviction of the older adult victim, co-dependency and involvement of the older adult in the procurement of illicit substances, and substance use by the older adult. Respondents specifically expressed concerns that the opioid epidemic, including rising heroin use, may be changing the frequency and nature of elder abuse, and that case investigations offer an opportunity to facilitate referrals for formal substance use disorder assessment and treatment. Future work includes additional focus groups and quantitative analysis to clarify the intersection between substance use and elder abuse and inform intervention and prevention strategies.

Can artificial intelligence help identify elder abuse and neglect?

A health care encounter is a potentially critical opportunity to detect elder abuse and initiate intervention. Unfortunately, health care providers currently very seldom identify elder abuse. Through development of advanced data analytics techniques such as machine learning, artificial intelligence has the potential to dramatically improve elder abuse identification in health care settings.

Psychiatric Case Review and Treatment Intensification in Collaborative Care Management for Depression in Primary Care

OBJECTIVE

This study examined whether psychiatric case review was associated with depression medication modification in a large implementation program of collaborative care for depression in safety-net primary care clinics.

METHODS

Registry data were examined from an implementation of the collaborative care model in Washington State. A total of 14,960 adults from 178 primary care clinics who initiated care between January 1, 2008, and September 30, 2014, and who had a baseline Patient Health Questionnaire-9 (PHQ-9) score of 10 or higher were included. Rates of psychiatric case reviews and receipt of new depression medications were extracted from the registry for all patients and for a subset of patients who did not improve by eight weeks of treatment (did not achieve a PHQ-9 score of less than 10 or a reduction in PHQ-9 score of 50% or more, compared with baseline).

RESULTS

One-half of patients received a new depression medication. Psychiatric case review in any given month was associated with a doubling of the probability of receiving a new medication in the following month. Among patients who did not improve by eight weeks of treatment, a psychiatric case review during weeks 8-12 was associated with a higher rate of receipt of new medications during weeks 8-16 or weeks 8-20.

CONCLUSIONS

In a collaborative care program, psychiatric case review was associated with higher rates of subsequent receipt of a new depression medication. This finding supports the importance of psychiatric case review in reducing clinical inertia in collaborative care treatment of depression.