Hospital And ED Use Among Medicare Beneficiaries With Dementia Varies By Setting And Proximity To Death

Abstract

Hospitalizations and emergency department (ED) visits for people with Alzheimer's disease and related disorders are of particular concern because many of these patients are physically and mentally frail, and the care delivered in these settings is costly. Using data from the Health and Retirement Study linked with Medicare claims from the period 2000-08, we found that among community-dwelling elderly fee-for-service Medicare beneficiaries, those who had dementia were significantly more likely than those who did not to have a hospitalization (26.7 percent versus 18.7 percent) and an ED visit (34.5 percent versus 25.4 percent) in each year. Comparing nursing home residents who had dementia with those who did not, we found only small differences in hospitalizations (45.8 percent versus 41.9 percent, respectively) and ED use (55.3 percent versus 52.7 percent). As death neared, however, utilization rose sharply across settings and by whether or not beneficiaries had dementia: Nearly 80 percent of community-dwelling decedents were hospitalized, and an equal proportion had at least one ED visit during the last year of life, regardless of dementia. Our research suggests that substantial portions of hospitalizations and ED visits both before and during the last year of life were potentially avoidable. A lzheimer's disease and related disorders place substantial emotional, physical, and financial burdens on patients, their families, and society. One important source of these burdens is frequent hospitalizations and emergency department (ED) visits, many of which are potentially avoidable. These encounters are disruptive, costly, and particularly challenging for people with dementia, who are vulnerable to many adverse health outcomes, including delirium, 1 falls, 2 functional decline, 3 physical restraints, 4 and agitation and related behavioral symptoms. 5These problems are aggravated by the poor communication abilities and coexisting medical conditions associated with dementia. 6 Older people with dementia also have special difficulties in transitioning across care settings. 7 Hence, unnecessary or potentially avoidable hospitalizations and ED visits have important implications for both the quality of care and the quality of life for people with dementia, 8,9 especially at the end of life. 10Few studies have focused on hospital and ED use, especially potentially avoidable use, among older people with dementia.11-14 As a result, current understanding of hospital and ED use by people who have dementia compared to use by people who do not remains limited. Furthermore, there have been few analyses of the impact of dementia on hospital and ED use across community and institutional settings.

Direct medical costs and source of cost differences across the spectrum of cognitive decline: A population‐based study

“…Based on reasons for admission recorded in billing data (i.e., principal discharge diagnosis codes), it is increasingly suggested that persons with dementia are over-hospitalized, and many hospitalizations are potentially preventable. [20,21,65,69,71-73,79]. Our findings do not appear to suggest excessive use of surgery in dementia patients—there is a possibility that surgery is underutilized.…”

“…[65-68] Regarding comparisons between prevalent dementia and CN, our results reflect pooled conclusions by others that a) medical costs are higher for individuals with dementia compared to those without dementia; b) differences are especially great for hospital inpatient costs; c) among hospitalized patients, those with dementia are admitted for different reasons and longer stays; d) dementia subjects with selected comorbid conditions have higher costs than those for subjects with similar conditions but no dementia; and e) dementia-associated use is reduced following adjustment for comorbidity. [3,5,19,20,23,69-73]…”

Distress Associated with Dementia-Related Psychosis and Agitation in Relation to Healthcare Utilization and Costs

“…Older adults with dementia are at increased risk of hospital admission for reasons that are not clear (1–3). Potential contributing factors that have been largely unaddressed are the behavioral and psychological symptoms of dementia (BPSD [also referred to as neuropsychiatric symptoms]) and associated caregiver distress.…”

“…Previous analyses have found an association between BPSD and medical costs, although BPSD were simply categorized as “high” (13) or “present” (14) in those studies, and the role of caregiver distress was not considered. In addition, costs were estimated from a caregiver survey and emergency department (ED) utilization was not considered, although ED use is known to be elevated in patients with dementia (3). A recent prospective Scottish cohort study found high overall BPSD to be associated with hospital admission, although overall caregiver distress was not significant; ED utilization was not considered (15).…”

Variations Among Medicare Beneficiaries Living in Different Settings

“…The Census found that from 2000 to 2010, the number and proportion of elderly living in facilities declined while the overall population of elderly grew. Feng et al found comparable rates of emergency department use in community dwelling elderly and nursing home residents with dementia from 2000 to 2008; however they did not separately analyze people living in assisted living or other community plus services settings (14). Caffrey (8) reported similar rates of Medicaid use among people living in community plus services settings.…”