“Acute illnesses requiring hospitalization serve as a sentinel event, with many older adults requiring assistance with activities of daily living (ADLs) upon discharge,” explains Cameron J. Gettel, MD. “Loss of independence in ADLs has been associated with nursing home (NH) utilization, caregiver burden, and mortality. Prior research has noted the long-term disabling impact of critical conditions (eg, myocardial infarction, stroke), but a knowledge gap exists regarding the subsequent functional disability, recovery, and incident NH admission among older adults who are hospitalized for ambulatory care sensitive conditions (ACSCs). Investigating these patient-centered measures after ACSC-related hospitalizations could provide valuable supporting evidence for the continued role of ACSC-related hospitalizations in national quality payment programs set forth by CMS.”

Patient-Reported Disability Scores Recorded

For a paper published in the Journal of Hospital Medicine, Dr. Gettel and colleagues sought to describe, among individuals who had a hospitalization with an ACSC (eg, urinary tract infection, congestive heart failure, angina without procedure) as the primary diagnosis on linked Medicare claims data, the following:

  1. 6-month course of post-discharge functional disability.
  2. Cumulative monthly probability of functional recovery.
  3. Cumulative monthly probability of incident NH admission.

Participants were drawn from the Precipitating Events Project (PEP) study, an ongoing prospective, longitudinal study. The analytic sample included 251 ACSC-related hospitalizations from a cohort of 754 non-disabled community-living patients aged 70 and older interviewed monthly for up to 19 years. During monthly interviews, patient-reported disability scores in basic, instrumental, and mobility activities were determined. Functional recovery was defined as returning, within 6 months of discharge, to a total disability score less than or equal to that immediately preceding hospitalization. All incident NH admissions, including both short- and long-term stays, were identified using the CMS Skills Nursing Facility claims file and Long-Term Care Minimum Data Set.

Clinically Meaningful Adverse Outcomes

“Following the ACSC-related hospitalizations, we observed that total disability scores peaked at month 1 and improved modestly during the next 5 months but remained greater than the pre-hospitalization score,” Dr. Gettel says. The researchers discovered that the three most common reasons for ACSC-related hospitalizations were congestive heart failure, bacterial pneumonia, and dehydration. Recovery was incomplete, with only 70% of hospitalizations achieving a return to the pre-hospitalization total disability count within 6 months of hospitalization (Table 1). Of the 251 ACSC-related hospitalizations, incident NH admission was experienced by 38% within 1 month and 50% within 6 months of discharge. Short-term NH stays accounted for 90 (75.6%) of the 119 incident NH admissions within the 6 months after ACSC-related hospitalizations (Table 2).

“Our findings provide evidence that older adults experience clinically meaningful adverse patient-reported outcomes after ACSC-related hospitalizations,” Dr. Gettel says.  “Prior research involving ACSCs has focused largely on rates of hospitalization as a measure of access to primary care and the associated factors predictive of ACSC-related hospitalizations and has not addressed subsequent patient-reported outcomes. The findings in our analysis show that older adults experience worsening disability immediately after an ACSC-related hospitalization, which persists for prolonged periods and often results in incomplete recovery.”

Dr. Gettel and colleagues note that their work is relevant to the continued evaluation of ACSC-related hospitalizations in national quality measurement and payment initiatives among Medicare beneficiaries. “Having demonstrated adverse outcomes after ACSC-related hospitalizations, this research may help support the need for, as well as reimbursement for, interventions like home-based care or telehealth that target potentially preventable ACSC-related hospitalizations,” he says. “Finally, hospital discharge planning could include preparing older adults for anticipated functional disabilities, associated recoveries, and NH admission after ACSC-related hospitalizations.”

The study team, according to Dr. Gettel, would like to see future research identify at-risk populations. “In this way, interventions could be offered earlier in the course of care to those who would benefit most,” he adds. “Researchers should also identify and learn from those who are resilient and have recovered, to better understand factors contributing to their success.”