Hospital Readmission andUnmet Need for ADL Disability

Glen DePalma

November 20, 2011

Introduction

Rehospitalization is costly with annual estimates exceeding 17 billiondollars.

Rehospitalization increases patients’ risk for negative health eventsincluding functional decline.

I 1 in 6 older adults lose ADL functioning during hospitalization and donot recover that function in the months after discharge.

More than half of hospitalized older Medicare recipients arerehospitalized within a year.

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Motivation

It is important to find modifiers that reduce the risk of rehospitalization.

I More than 1 in 4 adults are discharged to the community with unmetneed for new or existing ADL disabilities.

The purpose of this study was to determine whether unmetneed is associated with increased risk for rehospitalization.

I Is risk for hospitalization greater for those with unmet need fornewly acquired ADL disabilities compared to those whose unmetneed was for disabilities that existed before the indexhospitalization?

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Motivation

It is important to find modifiers that reduce the risk of rehospitalization.

I More than 1 in 4 adults are discharged to the community with unmetneed for new or existing ADL disabilities.

The purpose of this study was to determine whether unmetneed is associated with increased risk for rehospitalization.

I Is risk for hospitalization greater for those with unmet need fornewly acquired ADL disabilities compared to those whose unmetneed was for disabilities that existed before the indexhospitalization?

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Data

Data are from the 1994, 1999 and 2004 community surveys from theNational Long Term Care Survey (NLTCS) and linked Medicareinpatient claims from 1993 onwards.

Participants in the NLTCS samples were selected Medicare enrolleesusing a two-stage sampling scheme.

Response rates to the community surveys were 95% or higher exceptfor 2004 in which the response rate was closer to 90%.

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Sample

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Definition of ADL Disability and Unmet Need

Types of ADL Tasks:1 Bathing2 Dressing3 Eating4 Toileting5 Getting out of bed or moving around a room

ADL Disability was determined through a series of questions foreach ADL task

I Need help? Received help? Used equipment?

Unmet Need was determined for each ADL disabilityI If you don’t have help, could you use help? If you do have help, do you

need more help?I If a subject had unmet need in at least one ADL disability then they

were classified as having unmet need.

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Definition of ADL Disability and Unmet Need

Types of ADL Tasks:1 Bathing2 Dressing3 Eating4 Toileting5 Getting out of bed or moving around a room

ADL Disability was determined through a series of questions foreach ADL task

I Need help? Received help? Used equipment?

Unmet Need was determined for each ADL disabilityI If you don’t have help, could you use help? If you do have help, do you

need more help?I If a subject had unmet need in at least one ADL disability then they

were classified as having unmet need.

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Definition of ADL Disability and Unmet Need

Types of ADL Tasks:1 Bathing2 Dressing3 Eating4 Toileting5 Getting out of bed or moving around a room

ADL Disability was determined through a series of questions foreach ADL task

I Need help? Received help? Used equipment?

Unmet Need was determined for each ADL disabilityI If you don’t have help, could you use help? If you do have help, do you

need more help?I If a subject had unmet need in at least one ADL disability then they

were classified as having unmet need.

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Variables Shown in Prior Researchto be Associated with Risk for Readmission

Unmet Need?

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Variables Shown in Prior Researchto be Associated with Risk for Readmission

Unmet Need?

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Statistical Analyses

A Cox proportional hazards model was used to assess the risk ofrehospitalization for unmet need after adjusting for knowndemographic, health status, and functional risks for readmission.

Sampling weights obtained from the NLTCS were used in theanalyses.

Subjects who were admitted to a skilled nursing facility, died, orremained in the community 365 days after interview date werecensored.

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Bivariate Associations with Unmet Need

Effect Rehospitalized % Hazard RatioRace (white) 56 -

Other 68 1.59Proxy (no) 53 -

Yes 69 1.60Diabetes (no) 52 -

Yes 70 1.69Number ADL Disability (1-2) 47 -

3-5 66 1.72Previous Hospital Admissions 1.52Unmet Need (no) 52 -

Yes 73 1.68

*All variables significant at the alpha = .05 level

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Multivariable Model for Rehospitalization

Effect Hazard Ratio (95% CI)Age 1.02 (1.00, 1.04)Previous Admissions 1.51 (1.37, 1.67)Diabetes

Yes 1.53 (1.16, 2.02)Number ADL Disability

3-5 1.41 (1.05, 1.89)Unmet Need

Yes 1.37 (1.03, 1.82)

Variables determined by backwards selection.

Unmet need is associated with a further increase in hospital readmissionafter adjusting for demographic, health status, and functional disability.

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Multivariable Model for Rehospitalization

Effect Hazard Ratio (95% CI)Age 1.02 (1.00, 1.04)Previous Admissions 1.51 (1.37, 1.67)Diabetes

Yes 1.53 (1.16, 2.02)Number ADL Disability

3-5 1.41 (1.05, 1.89)Unmet Need

Yes 1.37 (1.03, 1.82)

Variables determined by backwards selection.

Unmet need is associated with a further increase in hospital readmissionafter adjusting for demographic, health status, and functional disability.

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Unmet Need for New vs. Existing ADL Disability

New unmet need is defined as having an unmet need for an ADL disabilitydeveloped in the last 3 months.

Effect Hazard Ratio (95% CI)Age 1.02 (1.00, 1.04)Previous Admissions 1.53 (1.38, 1.69)Diabetes

Yes 1.55 (1.18, 2.04)Number ADL Disability

3-5 1.39 (1.03, 1.88)Unmet Need

Existing 1.22 (0.90, 1.65)New 2.02 (1.24, 3.30)

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Kaplan - Meier Curve

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Limitations

Data are not available to describe the mechanism by which unmetneed for ADL disabilities increases risk for rehospitalization.

Data are not available to determine whether patients had insufficienthelp in other aspects of self-care that are commonly included in oldersurgical or medical patients discharge plans such as medicationadministration.

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Implications

The transition from hospital to home can be difficult for older adults.I Especially for functionally disabled adults.

Medicare patients who report unmet need after returning home fromthe hospital are at a higher risk for rehospitalization than those whodo not report unmet need.

Patients who report unmet need for new ADL disabilities are atgreater risk for rehospitalization than those who report unmet needfor ADL disabilities that existed prior to the index hospitalization.

Patients’ current and future functional needs should be carefullyevaluated and addressed before discharge.

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Implications

The transition from hospital to home can be difficult for older adults.I Especially for functionally disabled adults.

Medicare patients who report unmet need after returning home fromthe hospital are at a higher risk for rehospitalization than those whodo not report unmet need.

Patients who report unmet need for new ADL disabilities are atgreater risk for rehospitalization than those who report unmet needfor ADL disabilities that existed prior to the index hospitalization.

Patients’ current and future functional needs should be carefullyevaluated and addressed before discharge.

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Acknowledgements

Ken Covinksy - Professor of Medicine - University of California

Bruce Craig - Professor of Statistics - Purdue University

Laura Sands - Professor of Nursing - Purdue University

Eric Stallard - Professor of Demography - Duke University

Joesph Thomas - Professor of Pharmacy Practice - Purdue University

Huiping Xu - Asst. Professor of Biostatistics - Indiana University School of Medicine

This research was funded by a grant from the National Institutes of Health(R01AG034160) to L.P. Sands.

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