@article {9154, title = {Functional impairment: An unmeasured marker of Medicare costs for postacute care of older adults.}, journal = {Journal of the American Geriatrics Society}, volume = {65}, year = {2017}, month = {09/2017}, pages = {1996-2002}, abstract = {

OBJECTIVES: To assess the effects of preadmission functional impairment on Medicare costs of postacute care up to 365 days after hospital discharge.

DESIGN: Longitudinal cohort study.

SETTING: Health and Retirement Study (HRS).

PARTICIPANTS: Nationally representative sample of 16,673 Medicare hospitalizations of 8,559 community-dwelling older adults from 2000 to 2012.

MEASUREMENTS: The main outcome was total Medicare costs in the year after hospital discharge, assessed according to Medicare claims data. The main predictor was functional impairment (level of difficulty or dependence in activities of daily living (ADLs)), determined from HRS interview preceding hospitalization. Multivariable linear regression was performed, adjusted for age, race, sex, income, net worth, and comorbidities, with clustering at the individual level to characterize the association between functional impairment and costs of postacute care.

RESULTS: Unadjusted mean Medicare costs for 1 year after discharge increased with severity of impairment in a dose-response fashion (P < .001 for trend); 68\% had no functional impairment ($25,931), 17\% had difficulty with one ADL ($32,501), 7\% had dependency in one ADL ($39,928), and 8\% had dependency in two or more ADLs ($45,895). The most severely impaired participants cost 77\% more than those with no impairment; adjusted analyses showed attenuated effect size (33\% more) but no change in trend. Considering costs attributable to comorbidities, only three conditions were more expensive than severe functional impairment (lymphoma, metastatic cancer, paralysis).

CONCLUSION: Functional impairment is associated with greater Medicare costs for postacute care and may be an unmeasured but important marker of long-term costs that cuts across conditions.

}, keywords = {Functional limitations, Medicare linkage, Medicare/Medicaid/Health Insurance}, issn = {1532-5415}, doi = {10.1111/jgs.14955}, author = {S. Ryan Greysen and Irena Cenzer and W John Boscardin and Kenneth E Covinsky} } @article {8313, title = {Functional impairment and hospital readmission in Medicare seniors.}, journal = {JAMA Intern Med}, volume = {175}, year = {2015}, note = {Times Cited: 0 0}, month = {2015 Apr}, pages = {559-65}, publisher = {175}, abstract = {

IMPORTANCE: Medicare currently penalizes hospitals for high readmission rates for seniors but does not account for common age-related syndromes, such as functional impairment.

OBJECTIVE: To assess the effects of functional impairment on Medicare hospital readmissions given the high prevalence of functional impairments in community-dwelling seniors.

DESIGN, SETTING, AND PARTICIPANTS: We created a nationally representative cohort of 7854 community-dwelling seniors in the Health and Retirement Study, with 22,289 Medicare hospitalizations from January 1, 2000, through December 31, 2010.

MAIN OUTCOMES AND MEASURES: Outcome was 30-day readmission assessed by Medicare claims. The main predictor was functional impairment determined from the Health and Retirement Study interview preceding hospitalization, stratified into the following 5 levels: no functional impairments, difficulty with 1 or more instrumental activities of daily living, difficulty with 1 or more activities of daily living (ADL), dependency (need for help) in 1 to 2 ADLs, and dependency in 3 or more ADLs. Adjustment variables included age, race/ethnicity, sex, annual income, net worth, comorbid conditions (Elixhauser score from Medicare claims), and prior admission. We performed multivariable logistic regression to adjust for clustering at the patient level to characterize the association of functional impairments and readmission.

RESULTS: Patients had a mean (SD) age of 78.5 (7.7) years (range, 65-105 years); 58.4\% were female, 84.9\% were white, 89.6\% reported 3 or more comorbidities, and 86.0\% had 1 or more hospitalizations in the previous year. Overall, 48.3\% had some level of functional impairment before admission, and 15.5\% of hospitalizations were followed by readmission within 30 days. We found a progressive increase in the adjusted risk of readmission as the degree of functional impairment increased: 13.5\% with no functional impairment, 14.3\% with difficulty with 1 or more instrumental activities of daily living (odds ratio [OR], 1.06; 95\% CI, 0.94-1.20), 14.4\% with difficulty with 1 or more ADL (OR, 1.08; 95\% CI, 0.96-1.21), 16.5\% with dependency in 1 to 2 ADLs (OR, 1.26; 95\% CI, 1.11-1.44), and 18.2\% with dependency in 3 or more ADLs (OR, 1.42; 95\% CI, 1.20-1.69). Subanalysis restricted to patients admitted with conditions targeted by Medicare (ie, heart failure, myocardial infarction, and pneumonia) revealed a parallel trend with larger effects for the most impaired (16.9\% readmission rate for no impairment vs 25.7\% for dependency in 3 or more ADLs [OR, 1.70; 95\% CI, 1.04-2.78]).

CONCLUSIONS AND RELEVANCE: Functional impairment is associated with increased risk of 30-day all-cause hospital readmission in Medicare seniors, especially those admitted for heart failure, myocardial infarction, or pneumonia. Functional impairment may be an important but underaddressed factor in preventing readmissions for Medicare seniors.

}, keywords = {Activities of Daily Living, Age Factors, Aged, Aged, 80 and over, Cohort Studies, Comorbidity, Female, Heart Failure, Humans, Income, Logistic Models, Male, Medicare, Myocardial Infarction, Patient Readmission, Pneumonia, Risk Assessment, Risk Factors, Sex Factors, United States}, issn = {2168-6114}, doi = {10.1001/jamainternmed.2014.7756}, author = {S. Ryan Greysen and Irena Cenzer and Andrew D. Auerbach and Kenneth E Covinsky} }