facilities have better June 27, 2017 outcomes? - - PowerPoint PPT Presentation
Do assisted-living residents Portia Y. Cornell, M.S.P.H., Ph.D. Academy Health ARM in dementia-licensed New Orleans, LA facilities have better June 27, 2017 outcomes? Portia_Cornell@brown.edu Specialized dementia-care units: licensing
Portia Y. Cornell, M.S.P.H., Ph.D. Academy Health ARM New Orleans, LA June 27, 2017 Portia_Cornell@brown.edu
Some states issue special license
Licensing requirements differ by
Secured to prevent wandering Training requirements Staff-to-resident ratios 2
Information asymmetries between prospective resident and
Dementia-specialized-care license is a “signal” of underlying
Key insight: cost of licensure is lower for higher-quality facilities Limitation: prospective don’t update their beliefs from experience
3
Licensing requirements directly impact patient outcomes License is a signal of deeper specialization & capacity
4
Informatio n
AL Community Prospective resident
Does living in a dementia-specialized assisted-living facility,
Outcomes: Mortality Hospice use Emergency department visits Inpatient hospital days 5
Linear model effect of residing in dementia-licensed AL Instrumental variable analysis Stratify by dual status and state
6
Log-distance difference:
D1 = distance to nearest non-specialized AL community D2 = distance to nearest dementia-specialized AL community lnDD = ln(D1) – ln(D2)
7
Regular assisted-living residence Dementia-licensed assisted-living residence
D1 D2 D1 D2 lnDD<0 lnDD>0 With increasing lnDD, more likely to move to a dementia- licensed residence
Medicare fee-for-service beneficiaries with validated residence
Alabama, Colorado, Mississippi, New York
Diagnosis of dementia in 2011, 2012, or 2013 Previous residence in 2011 or 2012 NOT in assisted living
8
9
Non-dementia- licensed Dementia- licensed Total Age 80.56 83.90 81.24 Female 68% 70% 69% Race=Black 8% 3% 7% Race=Other non-white 3% 1% 2% Dual Medicare/Medicaid 43% 14% 37% Inpatient days 2.49 1.11 2.21 Skilled nursing days 12.22 7.97 11.36 ED visits 1.01 0.63 0.93 Heart problems 63% 59% 62% Stroke/TIA 11% 11% 11% Kidney disease 29% 25% 29% Hip fracture 5% 5% 5% County: pct in poverty 15.60 14.19 15.32 County: median hh income 57026 60562 57740
10
Probability of dementia-licensed AL increases with instrument F-statistics >10
11
0.00 0.10 0.20 0.30
Age<60 Age<70 Age<80 Age>=80 female black
inpatient_days snf_days er_visits heart stroke kidney hipfracture poverty_pct median_hh_inc
Standardized Difference Change from Treatment to Instrument
Duals Instrument Duals Treatment Non-duals Instrument Non-duals Treatment
12
Mean outcomes among study sample Duals(N=2114) Non-Duals (N=3606) Mortality (died in 2013) 0.14 0.13 Hospice (any) 0.06 0.08 Emergency Dept Visits† 0.10 0.09 Hospital Inpatient Days† 0.23 0.11 Skilled Nursing Days† 1.25 1.24 † Adjusted for observed months
13
Effect of living in a dementia-specialized assisted-living residence compared to non-specialized Duals (N=2114) Non-Duals (N=3606) Mortality (died in 2013) 0.35*** 0.04 Hospice (any) 0.28*** 0.07** Emergency Dept Visits† 0.06 0.01 Hospital Inpatient Days† 0.34 0.09 Skilled Nursing Days† 0.29
*p<0.10, **p<0.05, ***p<0.01 † Adjusted for observed months
14
15
16
17
Dementia-specialized communities increase mortality?
Inefficient allocation of resources
Value independence and quality of life over safety and prolonging
Increase use of Medicare hospice benefit suggests different priorities
Geographic differences?
E.g.: frail individuals may choose assisted living over a nursing-home
special-care-unit if there is a dementia-specialized facility nearby
18
IV addresses patient-level selection, but NOT geographic
Within a dementia-licensed community with both specialized and
19
Kali S. Thomas & Momotazur Rahman, co-authors National Institute on Aging grant (R21 AG047303; PI, K.S. Thomas) Veterans Administration OAA Advanced Fellowship Contact: Portia_Cornell@brown.edu
20
Carder P, O’Keeffe J, O’Keeffe C. Compendium of Residential Care and Assisted Living Regulations and Policy: 2015 Edition. 2015. Prepared by RTI International for the Office of Disability, Aging, and Long-Term Care Policy, Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. Harris-Kojetin L, Sengupta M, Park-Lee E, et al. 2016. Long-term care providers and service users in the United States: Data from the National Study of Long-term Care Providers, 2013-14. National Center for Health Statistics. Vital Health Stat 3(38). Spence M. 1973. Job Market Signaling. Quarterly Journal of Economics 87(3):355-374. Thomas K, Dosa D, Gozalo PL, Grabowski DC, Nazareno J, Makineni R, Mor V . A methodology to Identify a Cohort of Medicare Beneficiaries Residing in Large Assisted Living Facilities Using Administrative Data 21
.2 .4
2
AL
.2 .4
2 4
CO
.2 .4
5
MS
.2 .4
2 4
NY
Propensity to move to dementia-specialized AL 95% CI Smoothed average
23
Effect of living in a dementia-specialized assisted-living residence compared to non-specialized Duals (N=2114) Pct mean Non-Duals (N=3606) Pct mean Mortality (died in 2013) 0.35*** 250% 0.04 34% Hospice (any) 0.28*** 496% 0.07** 85% Emergency Dept Visits† 0.06 57% 0.01 10% Hospital Inpatient Days† 0.34 150% 0.09 78% Skilled Nursing Days† 0.29 23%
*p<0.10, **p<0.05, ***p<0.01 † Adjusted for observed months