WASHINGTON – During the last year of life for community-dwelling elders, up to three-fourths of hospital visits might have been avoidable.
Nursing home residents also were susceptible to potentially unnecessary admissions, with about 50% experiencing at least one avoidable visit during the final months, Dr. Zhanlian Feng said at a briefing to unveil the April special issue of Health Affairs, "The Long Reach of Alzheimer’s Disease."
Dementia was a significant contributor to hospital and emergency department use: Those with dementia were 74% more likely to have a potentially avoidable hospitalization and 51% more likely to have had a potentially avoidable ED visit.
The researchers did not speculate on what care might have been more appropriate for these patients, said Dr. Feng, a senior research public health analyst in the Aging, Disability, and Long-Term Care program at RTI International, Waltham, Mass. It does, however, suggest a very high level of caregiver anxiety about dealing with a loved one’s acute health issues.
"It’s much more challenging to provide care and support for someone who is living at home," he said in an interview. "Whenever their loved one gets worse, the caregiver is worried about how to respond to the new crisis. Often they believe their only option is the emergency department."
At-home care "is probably a big driver of hospital utilization," among the elderly, and one to which policy makers may be blind, he said in an interview.
"There are many initiatives designed to reduce hospitalizations among the elderly, but they focus almost exclusively on nursing homes, and don’t target people with dementia in particular. In the community setting, there is very little discussion on how to accomplish this."
At the briefing, Dr. Feng discussed his study, which was published April 7 in Health Affairs (Health Aff. 2014;33:683-90). It looked at hospitalization and emergency department use among more than 12,000 Medicare beneficiaries who were included in the Health and Retirement Study during 2000-2008. The study included four outcomes: 5-year hospital/ED utilization among elders with and without dementia, and hospital/ED utilization among both groups within the last year of life.
Potentially avoidable conditions were considered to be those that could have been effectively dealt with in the patients’ out-of-hospital care setting with community-based resources or within a long-term care or nursing home facility.
Some of these problems included heart failure and chronic obstructive pulmonary disease, blood pressure complications, hyper- and hypoglycemia, diabetes, dehydration or diarrhea, electrolyte imbalances, constipation or fecal impaction, urinary and respiratory tract infections (including some pneumonias), and skin ulcers. Problems relating to malnutrition and asthma also were included.
There were some differences among these groups, however. "For example, acute, severe diarrhea due to gastroenteritis or food poisoning can often be managed in nursing homes without hospitalization, but patients with the same condition in the community may require hospitalization."
ED visits that resulted in admission weren’t included because the authors assumed that those represented unavoidable admissions. They conducted a multivariate analysis that controlled for age, gender, race/ethnicity, income, education, marital status, other insurance, chronic health problems, self-reported health, and the ability to perform activities of daily living.
Dementia was significantly more common among nursing home residents than among community residents (84% vs. 12%). Almost half (44%) of those who died had dementia in the last year of life.
Dr. Feng said that more than a quarter of community-dwelling elders with dementia (27%) were hospitalized each year, a rate significantly higher than that among those without dementia (19%). And, he said, significantly more of these admissions were considered potentially avoidable among dementia patients (8% vs. 5%).
Significantly more ED visits occurred among those with dementia (24% vs. 18%) with significantly more deemed potentially preventable among dementia patients (5% vs. 3%). And significantly more patients with dementia were admitted as a result of these visits (19% vs. 12%).
After adjustment for the variables, dementia was a significant contributor to all of these outcomes. Dementia patients were 74% more likely to have an avoidable hospitalization and 51% more likely to have an avoidable ED visit than were patients without dementia.
Nursing home residents also had high hospital and ED utilization each year, but there were no significant differences between those with and without dementia. Still, Dr. Feng said, "About half of these hospitalizations and ED visits might have been preventable."
Utilization skyrocketed in the last year of life, he said. About 80% of community dwellers, regardless of dementia status or living situation, had at least one hospitalization or ED visit during that time, and up to 75% of these might have been unnecessary.