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

BACKGROUND: There has been a marked rise in the use of observation care for Medicare beneficiaries visiting the emergency department (ED) in recent years. Whether trends in observation use differ for people with Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) is unknown. METHODS: Using a national 20% sample of Medicare beneficiaries ages 68+ from 2012 to 2018, we compared trends in ED visits and observation stays by AD/ADRD status for beneficiaries visiting the ED. We then examined the degree to which trends differed by nursing home (NH) residency status, assigning beneficiaries to four groups: AD/ADRD residing in NH (AD/ADRD+ NH+), AD/ADRD not residing in NH (AD/ADRD+ NH-), no AD/ADRD residing in NH (AD/ADRD- NH+), and no AD/ADRD not residing in NH (AD/ADRD- NH-). RESULTS: Of 7,489,780 unique beneficiaries, 18.6% had an AD/ADRD diagnosis. Beneficiaries with AD/ADRD had more than double the number of ED visits per 1000 in all years compared to those without AD/ADRD and saw a faster adjusted increase over time (+26.7 vs. +8.2 visits/year; p < 0.001 for interaction). The annual increase in the adjusted proportion of ED visits ending in observation was also greater among people with AD/ADRD (+0.78%/year, 95% CI 0.77-0.80%) compared to those without AD/ADRD (+0.63%/year, 95% CI 0.59-0.66%; p < 0.001 for interaction). Observation utilization was greatest for the AD/ADRD+ NH+ population and lowest for the AD/ADRD- NH- population, but the AD/ADRD+ NH- group saw the greatest increase in observation stays over time (+15.4 stays per 1000 people per year, 95% CI 15.0-15.7). CONCLUSIONS: Medicare beneficiaries with AD/ADRD have seen a disproportionate increase in observation utilization in recent years, driven by both an increase in ED visits and an increase in the proportion of ED visits ending in observation.

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

BACKGROUND: Older 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. METHODS: We 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. RESULTS: We 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. CONCLUSIONS: Beneficiaries 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.

Association of Academic Medical Center Presence With Clinical Outcomes at Neighboring Community Hospitals Among Medicare Beneficiaries.

Importance: Studies suggest that academic medical centers (AMCs) have better outcomes than nonteaching hospitals. However, whether AMCs have spillover benefits for patients treated at neighboring community hospitals is unknown. Objective: To examine whether market-level AMC presence is associated with outcomes for patients treated at nonteaching hospitals within the same markets. Design, Setting, and Participants: This retrospective, population-based cohort study assessed traditional Medicare beneficiaries aged 65 years and older discharged from US acute care hospitals between 2015 and 2017 (100% sample). Data were analyzed from August 2021 to December 2022. Exposures: The primary exposure was market-level AMC presence. Health care markets (ie, hospital referral regions) were categorized by AMC presence (percentage of hospitalizations at AMCs) as follows: no presence (0%), low presence (>0% to 20%), moderate presence (>20% to 35%), and high presence (>35%). Main Outcomes and Measures: The primary outcomes were 30-day and 90-day mortality and healthy days at home (HDAH), a composite outcome reflecting mortality and time spent in facility-based health care settings. Results: There were 22 509 824 total hospitalizations, with 18 865 229 (83.8%) at non-AMCs. The median (IQR) age of patients was 78 (71-85) years, and 12 568 230 hospitalizations (55.8%) were among women. Of 306 hospital referral regions, 191 (62.4%) had no AMCs, 61 (19.9%) had 1 AMC, and 55 (17.6%) had 2 or more AMCs. Markets characteristics differed significantly by category of AMC presence, including mean population, median income, proportion of White residents, and physicians per population. Compared with markets with no AMC presence, receiving care at a non-AMC in a market with greater AMC presence was associated with lower 30-day mortality (9.5% vs 10.1%; absolute difference, -0.7%; 95% CI, -1.0% to -0.4%; P < .001) and 90-day mortality (16.1% vs 16.9%; absolute difference, -0.8%; 95% CI, -1.2% to -0.4%; P < .001) and more HDAH at 30 days (16.49 vs 16.12 HDAH; absolute difference, 0.38 HDAH; 95% CI, 0.11 to 0.64 HDAH; P = .005) and 90 days (61.08 vs 59.83 HDAH; absolute difference, 1.25 HDAH; 95% CI, 0.58 to 1.92 HDAH; P < .001), after adjustment. There was no association between market-level AMC presence and mortality for patients treated at AMCs themselves. Conclusions and Relevance: AMCs may have spillover effects on outcomes for patients treated at non-AMCs, suggesting that they have a broader impact than is traditionally recognized. These associations are greatest in markets with the highest AMC presence and persist to 90 days.