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