Current issues of ACP Journal Club are published in Annals of Internal Medicine


Etiology

Rapid development of severe disability was associated with increased hospitalizations, costs, and nursing home admissions

ACP J Club. 1997 Jul-Aug;127:19. doi:10.7326/ACPJC-1997-127-1-019


Source Citation

Ferrucci L, Guralnik JM, Pahor M, Corti MC, Havlik RJ. Hospital diagnoses, Medicare charges, and nursing home admissions in the year when older persons become severely disabled. JAMA. 1997 Mar 5:277:728-34.


Abstract

Objective

To determine the relation between rapid or gradual development of severe disability and hospital diagnoses, Medicare charges, and nursing home admissions in the year when older persons become severely disabled.

Design

Population-based cohort study with ≥ 6 annual follow-up interviews.

Setting

3 communities in the United States: East Boston, Massachusetts; New Haven, Connecticut; and 2 counties in Iowa.

Participants

6070 participants ≥ 70 years of age (64% women, 95% white) who had first onset of severe disability (i.e., disability in ≥ 3 activities of daily living) after the fourth annual follow-up interview. Participants who had no disability in activities of daily living 2 years before development of severe disability were classified as having catastrophic disability (CD), and those who had disability in 1 or 2 activities of daily living 2 years before development of severe disability were classified as having progressive disability (PD).

Assessment of risk factors

To gather data on severity of disability and nursing home admissions, 6 annual follow-up interviews were done in East Boston and a total of 7 were done in Connecticut and Iowa. Hospitalization data were obtained from the Medicare Provider Analysis and Review database.

Main outcome measures

Disability in activities of daily living, hospitalization rate, principal discharge diagnoses, Medicare charges, diagnostic and surgical procedures, and nursing home admissions.

Main results

438 participants (7.2%) developed severe disability. 226 developed CD and 212 developed PD. 72% of participants with CD were hospitalized compared with 49% of those with PD. The 6 most common diagnoses were stroke, hip fracture, congestive heart failure, and pneumonia in both groups; coronary heart disease and cancer for CD; and diabetes and dehydration for PD. Hospitalizations for 1 of the 6 most common diagnoses occurred in 49% of participants with CD and in 25% of those with PD. Total hospital charges were higher for the CD group compared with the PD group. Charges for surgery, diagnostic procedures, and rehabilitation decreased with age for both CD and PD. Among the participants who did not previously reside in nursing homes, 57% of those with CD compared with 38% of those with PD were admitted to a nursing home (odds ratio 2.8, 95% CI 1.7 to 4.5).

Conclusion

Rapid development of severe disability in older persons was associated with an increase in hospitalizations, hospital charges, and nursing home admissions for a small group of diseases.

Source of funding: National Institute on Aging.

For article reprint: Dr. J.M. Guralnik, National Institute on Aging, Gateway Building, Suite 3C-309, 7201 Wisconsin Avenue, Bethesda, MD 20892, USA. FAX 301-496-4006.


Commentary

Today's focus on current medical cost containment includes close scrutiny of the financial implications of the demographic imperative. The growing medical budget can be blamed only in part on the demographic effects of an aging population. Increasing Medicare costs can be also attributed to inflation, new technologies, and the greater intensity of care (1). Appropriate allocation decisions about the latter 2 costs must come from the medical community.

Ferrucci and colleagues looked at the dynamic process of how aged persons developed severe disability. They compared a group of persons who were functionally well until sudden onset of a catastrophic disability with a group of patients who declined more slowly. In short, most older persons will be hospitalized when severe disability develops within a short period. As the authors point out, the study data sources do not elucidate how the common disabilities of arthritis and dementia affect the process of dysfunction. The investigators also could not determine the temporal sequence of onset of severe disability and hospitalization from the data sources, although the 2 were associated.

Tantalizing titles of articles in the geriatric literature support the notion that medical intervention can be safely applied in functionally competent patients of any age (2). The findings from the study by Ferrucci and colleagues support the concept that preventive strategies aimed at the 6 major diagnoses may be cost-effective, but an intervention study would be needed to test this.

Clinicians should continue to vigorously pursue and promote the perhaps mundane measures of treating osteoporosis, reducing other risks for stroke and heart disease, immunizing patients, and offering diet and exercise counseling to aged patients.

Charles V. Guida, MD
Southampton HospitalSouthampton, New York, USA

Charles V. Guida, MD
Southampton Hospital
Southampton, New York, USA


References

1. Lubitz JD, Riley GF. Trends in Medicare payments in the last year of life. N Engl J Med. 1993;328:1092-6.

2. Perler BA, Williams GM. Carotid endarterectomy in the very elderly: is it worthwhile? Surgery. 1994;116:479-83.