Hospital and Emergency Department Use by People with Alzheimer’s Disease and Related Disorders: Final Report

Executive Summary

Zhanlian Feng, PhD, Laurie Coots, MS, MA, Yevgeniya Kaganova, PhD, and Joshua Wiener, PhD

RTI International

August 2013

Introduction

Alzheimer's disease and related disorders (ADRD) affected approximately 4.7 million Americans age 65 or older in 2010. As the United States population ages, the number of people with ADRD is projected to increase dramatically in the coming decades, placing substantial emotional, physical, and financial burdens on patients, families, and society. One significant burden results from frequent, and often potentially avoidable, hospitalizations and emergency department (ED) visits, which have important implications for the quality of care and quality of life for people with ADRD or cognitive impairments. Understanding the patterns of hospital and ED use by people with ADRD or cognitive impairments relative to others without these conditions is crucial for developing appropriate policies to better address the care needs of this vulnerable population.

Methods

Using longitudinal, nationally representative data from the Health and Retirement Study (HRS) linked with Medicare claims over the 2000-2008 period, this study examined the effect of ADRD and cognitive impairment on hospitalizations and ED visits, both overall and potentially avoidable, and associated Medicare expenditures among fee-for-service (FFS) Medicare beneficiaries age 65 or older. Analyses compared utilization patterns across care settings (community vs. nursing home) and at different stages of the life course (several years before death vs. last year of life). Detailed utilization data are not available on Medicare beneficiaries enrolled in managed care organizations; therefore, beneficiaries enrolled in those health plans were excluded from the analysis. We developed a measure of severe cognitive impairment consistent with dementia by combining ADRD diagnoses from Medicare claims and a validated cognitive impairment measure from HRS, which incorporates information on cognitive functioning from both self and proxy reports.

We defined three broad categories of outcome variables: (1) hospitalizations, overall and whether potentially avoidable; (2) ED visits, overall and whether potentially avoidable; and (3) Medicare expenditures for each type of service use. Potentially avoidable hospitalizations or ED visits generally refer to hospital admissions or ED visits that may have been prevented with better primary care in community settings or treatment in a nursing home (for nursing home residents). We defined potentially avoidable hospitalizations and ED visits using a conservative set of conditions that experts deemed potentially preventable or manageable in community settings.

Results

Prevalence of cognitive impairment differs substantially by residential setting and proximity to death. Approximately 11% of community-dwelling Medicare beneficiaries age 65 or older were cognitively impaired, in contrast with 62% of those in nursing homes. The prevalence of cognitive impairments rose sharply at the time of death: 32% among community decedents, and 76% among nursing home decedents.

The impact of cognitive impairment on hospital and ED use varies by residential setting. Specifically, among community-dwelling beneficiaries, individuals with cognitive impairment are significantly more likely than those without cognitive impairment to be hospitalized and to have ED visits annually, both overall and for potentially avoidable conditions, after adjusting for demographic, socioeconomic, and health-related risk factors. For example, controlling for various factors, 25.6% of Medicare FFS beneficiaries with cognitive impairment had a hospitalization annually, compared with 17.5% of Medicare FFS beneficiaries without cognitive impairment. Moreover, controlling for various factors, 7.3% of beneficiaries with cognitive impairment had a potentially avoidable hospitalization, compared with 4.2% of people without cognitive impairment. In terms of ED visits, adjusting for various factors, 34.0% of beneficiaries with cognitive impairment had ED visits, compared with 24.4% of beneficiaries without cognitive impairment.

In contrast, among nursing home residents, there is no significant difference in hospitalization by cognitive impairment status, either overall or potentially avoidable. Although people with cognitive impairment in nursing homes do not have higher rates of hospitalizations and potentially avoidable hospitalizations than people without cognitive impairment, the absolute rates are quite high (nearly 50%). Moreover, more than 40% of nursing home residents with hospitalizations (both those with and without cognitive impairment) have potentially avoidable hospitalizations.

Hospital and ED use by people with and without cognitive impairment converge during the last few years of life. Among community decedents, there is no significant difference by cognitive impairment status in hospitalization in the last year of life, either overall (78.3% with cognitive impairment vs. 78.9% without cognitive impairment) or potentially avoidable (37.7% with cognitive impairment vs. 36.7% without cognitive impairment). Community decedents with cognitive impairments were more likely than those with no cognitive impairment to have an outpatient ED visit without admission in the last year of life (50.5% vs. 43.9%). A comparison of hospital and ED use patterns in the last 5 years of life between community-living beneficiaries with and without cognitive impairment showed a convergence in utilization as time to death becomes shorter. In addition, during the last year of life, hospital and ED use rose sharply relative to previous years, regardless of cognitive impairment status, and the utilization gap by cognitive impairment diminished.

Nursing home residents who died with cognitive impairment were significantly less likely than those without cognitive impairment to be hospitalized during the last year of life. Among nursing home decedents, individuals with cognitive impairment were significantly less likely than those without cognitive impairment to be hospitalized in their last year of life (67.9% vs. 77.9%). Other utilization outcomes during the last year of life did not vary by cognitive status.

Medicare expenditures associated with hospital and ED use for people with cognitive impairment and people without cognitive impairment differ by residential setting and proximity to death. In the overall analysis, average Medicare expenditures for people with cognitive impairment are higher than for people without cognitive impairment, regardless of setting. In contrast, we found lower average expenditures associated with hospitalizations in the last year of life for beneficiaries with cognitive impairment than those without cognitive impairment, both in the community and in nursing homes.

Conclusions

High rates of hospitalization and ED use among community-based people with cognitive impairments, both overall and for potentially avoidable conditions, may be attributable to multiple factors, such as challenges in providing adequate ambulatory care for people with cognitive impairments in community settings. In comparison, most nursing homes are equipped to provide medical and nursing care for many conditions that would be difficult to manage in community settings. Moreover, given the high prevalence of dementia in nursing homes, these facilities may be more used to treating people with ADRD than are community-based physicians. Although people with cognitive impairment in nursing homes do not have higher rates of hospitalizations and potentially avoidable hospitalizations than people without cognitive impairment, the high nominal rates for both groups suggests the importance of reducing unnecessary hospitalizations of nursing home residents.

In light of recent estimates indicating that the number of people age 65 or older with Alzheimer's disease will nearly triple by 2050, our results of hospital and ED use and associated Medicare expenditures underscore the importance of addressing issues specific to people with cognitive impairment. From the perspective of people with dementia and their caregivers, the high rates of hospitalizations and ED visits, especially those that are potentially avoidable, have clear implications for quality of life. Similarly, from the perspective of Medicare, the fact that a substantial portion of hospitalizations and ED use is potentially avoidable is of great policy significance because reducing inappropriate utilization in those settings provides a potential opportunity to achieve cost savings while improving quality; however, these savings may be offset by the cost of the initiatives to prevent potentially avoidable utilization. The findings from this study point to the continued need for planning and developing appropriate services and supports for older people with cognitive impairments in both community and institutional settings.