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Gender Differences in Critical Care Resource Utilization and Health Outcomes Among the Elderly

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Title: Gender Differences in Critical Care Resource Utilization and Health Outcomes Among the Elderly


1
Gender Differences in Critical Care Resource
Utilization and Health Outcomes Among the Elderly
  • Diane M. Dewar, PhD
  • University at Albany, State University of New
    York
  • Ming Lu, MS
  • Johns Hopkins University
  • Kimberly Dickson, BS, RRT
  • Hudson Valley Community College, New York
  • Funding source Agency for Healthcare Research
    and Quality

2
Critical Care Services are a Large Component of
the Health Economy
  • Critical care comprises
  • 20-34 of all hospital costs
  • 7-8 of total health care expenditures
  • 1-1.5 of U.S. GDP

3
Past Research Findings on Discharge and Health
Outcomes for Critically Ill
  • Discharge to post-acute settings
  • Inadequate reimbursement at the inpatient setting
    leads to increased use of extended care and home
    care
  • Placement delays occur due to bed shortages and
    lower reimbursement for alternative care
    settings
  • Increased use of PMV does not improve health,
    especially for the very old
  • Gender differences in service utilization and
    health outcomes
  • Some past research by others showed women with
    increased chance of survival in ICU but not for
    mechanical ventilation

4
Research Goals of this Study
  • To investigate
  • Whether elderly women have more or less
    utilization of hospital critical care services
    and case management support than men
  • Whether these women have differential health
    outcomes than men controlling for clinical risk
    and delivery system changes
  • What the independent impacts of gender and
    financing changes under the Health Care Reform
    Act (HCRA) of 1996 in NYS are on survival and
    discharge planning for seriously ill elderly with
    PMV

5
Relevance to Womens Health and Policy
  • This study is an extension of the literature in
    the delivery of care
  • Investigates gender differences among ICU
    patients in the utilization of health care
    resources and longer term health outcomes
  • The findings can be used to create policies that
    will increase access to care for the frail
    elderly
  • Important especially for women who have fewer
    social supports and financial access to care
    across venues

6
Relevance to General Health Policy
  • Past research had a lack of detailed information
    on how patterns of care affect health outcomes of
    patients with PMV
  • Major obstacle in setting policy for
    reimbursement and case management
  • This study contributes to literature by using a
    more detailed patient-level inpatient and
    post-discharge data base from a high volume
    631-bed non-profit teaching hospital for 1995 and
    1997
  • Results are used to determine whether more
    comprehensive analysis of patients is needed to
    asses system impacts on care and health outcomes

7
This Study is Part of a Larger Evaluation Project
  • The larger evaluation is of the impact of managed
    care and HCRA 1996 on the utilization of critical
    care, health outcomes and discharge locations of
    all mechanically ventilated patients discharged
    pre- and post-HCRA enactment
  • Assesses how cost control and market driven
    policy changes impact the health and subsequent
    health care of high-risk, high cost
    subpopulations in critical care (I.e., very old,
    women, chronically ill)

8
Methodology for This Womens Health Study
  • Retrospective analysis of medical records for 98
    elderly patients with PMV discharged from study
    hospital in 1995 and 1997
  • Detailed information on chronology of
    consultations, diagnoses, procedures
  • Qualitative information on provider perceptions
    of care delivery, social support network, needs
    for case management
  • Long term survival information from National
    Death Index
  • Logistic regression used to estimate the odds
    of
  • Gender related hospital survival
  • Gender related placement in skilled nursing
    facility (SNF) among survivors

9
Lower Competitive Reimbursements may Contribute
to Care Delivery Problems and Poorer Health
Outcomes
  • Females undergoing PMV in ICU have an increased
    likelihood of survival than males
  • Males have unobserved characteristics or
    experiences that lead to poorer health
  • Odds of survival decreased under HCRA enactment
  • 19 patients died within one year of discharge
  • 79 of these deaths occurred during HCRA enactment

10
Better Coordination of Care and Counseling
Services Yield Better Health Outcomes for the
Critically Ill
  • Patients with at least 1 social worker or case
    management visit had a greater chance of hospital
    survival
  • General reasons for social worker interventions
  • Pastoral care
  • Family support assessments
  • Coordination of rehabilitation services
  • General reasons for case management
    interventions
  • Patient follow-up
  • Discharge planning

11
Gender Comparisons in Coordination of Care
  • Reasons for social worker interventions differed
    between males and females
  • Females required more psychosocial interventions
  • Males required more coordination of care
    post-discharge
  • No significant gender-related difference in
    reasons for case management interventions

12
No Significant Difference in Odds of SNF
Discharges for Survivors, Controlling for
Delivery System Changes
  • Increased odds of SNF discharges associated
    with
  • Increased age
  • Enactment of HCRA
  • Reimbursement differential between inpatient and
    SNF settings lead to more placements
  • At least one social worker intervention
  • Lack of social support increased likelihood of
    SNF placement

13
Seriously Ill Women with PMV Have More Favorable
Health Outcomes than Men
  • Women have better health outcomes
  • More likely to survive in the short and longer
    terms post discharge
  • Women are no more likely to go to SNFs at
    discharge
  • Qualitative information show that this may be due
    to women more actively addressing family dynamic
    and psychosocial support networks
  • May result in more frequent home placements with
    nursing support

14
Findings have Significant Policy Relevance for
Womens Health Care
  • Study contributes to literature for the highest
    cost and highest risk patients in critical care
    setting
  • Identifies gender-specific impact on survival for
    elderly with PMV
  • Regardless of delivery system changes
  • May be due to unobservable differences in
    patients or care episode

15
Policy Recommendation Increase Use of Social
Worker Interventions
  • Study showed that social worker interventions
  • Addressed family system and caregiver issues
  • Lead to better coordination of discharges to
    venues other than SNFs
  • Improved access to care and associated health
    outcomes for elderly
  • Particularly useful for elderly women with less
    financial access to acute care and post-acute
    services

16
Additional Research is Needed on Impact of
Competitive Hospital Reimbursements on Long Term
Outcomes
  • Results showed and increase in SNF placements as
    HCRA was enacted, regardless of gender
  • Relevant to elderly population with greater
    likelihood of inappropriate or early discharges
  • More detailed information needed on patterns of
    care and Medical consultations for similarly
    diagnosed patients between 1995 and 1997
  • To determine if patterns of care have changed as
    a result of changes in reimbursements to increase
    discharges to other facilities
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