Trends in healthy days at home for Medicare beneficiaries using the emergency department

Abstract

BackgroundOlder adults, particularly those with Alzheimer's Disease and Alzheimer's Disease Related Dementias (AD/ADRD), have high rates of emergency department (ED) visits and are at risk for poor outcomes. How best to measure quality of care for this population has been debated. Healthy Days at Home (HDAH) is a broad outcome measure reflecting mortality and time spent in facility‐based healthcare settings versus home. We examined trends in 30‐day HDAH for Medicare beneficiaries after visiting the ED and compared trends by AD/ADRD status.MethodsWe identified all ED visits among a national 20% sample of Medicare beneficiaries ages 68 and older from 2012 to 2018. For each visit, we calculated 30‐day HDAH by subtracting mortality days and days spent in facility‐based healthcare settings within 30 days of an ED visit. We calculated adjusted rates of HDAH using linear regression, accounting for hospital random effects, visit diagnosis, and patient characteristics. We compared rates of HDAH among beneficiaries with and without AD/ADRD, including accounting for nursing home (NH) residency status.ResultsWe found fewer adjusted 30‐day HDAH after ED visits among patients with AD/ADRD compared to those without AD/ADRD (21.6 vs. 23.0). This difference was driven by a greater number of mortality days, SNF days, and, to a lesser degree, hospital observation days, ED visits, and long‐term hospital days. From 2012 to 2018, individuals living with AD/ADRD had fewer HDAH each year but a greater mean annual increase over time (p < 0.001 for the interaction between year and AD/ADRD status). Being a NH resident was associated with fewer adjusted 30‐day HDAH for beneficiaries with and without AD/ADRD.ConclusionsBeneficiaries with AD/ADRD had fewer HDAH following an ED visit but saw moderately greater increases in HDAH over time compared to those without AD/ADRD. This trend was visit driven by declining mortality and utilization of inpatient and post‐acute care.

Trends in observation stays for Medicare beneficiaries with and without Alzheimer's disease and related dementias

“…However, any efforts to further drive down admission rates for the AD/ADRD population must consider factors that are not traditionally available in claims data (e.g., social supports, functional status) 40 . While it is reassuring that outcomes have improved in recent years for emergency care for Medicare beneficiaries overall 41 and with AD/ADRD, 42 evidence specifically examining the impact of the apparent substitution of observation stays for inpatient care is needed in the AD/ADRD population. Our findings are also consistent with other work suggesting that community‐dwelling people with AD/ADRD are a distinct population with high rates of acute care utilization that differ from those in long‐term care settings 27,43 .…”