More than 10 percent of America's near-elderly population lacks public or private health insurance

The near elderly—those older than 50 but younger than 65—are more likely to suffer a decline in health, the loss of a spouse, and/or to leave the labor force via early retirement than younger people. Thus, people in this age group are at increased risk for losing their health insurance coverage.

There are several ways in which public programs and policies can help protect the near elderly from being uninsured. Some near elderly people may qualify for Medicaid, and others may be eligible for Medicare coverage due to disability. In addition, a number of State policies have been enacted to expand the availability of private health coverage. Despite these efforts, the proportion of near elderly in the United States without public or private coverage remained constant at 11.2 percent from 1992 to 1994, according to a recent study which was supported in part by the Agency for Health Care Policy and Research (HS08614).

Researchers Frank A. Sloan, Ph.D., and Christopher J. Conover, Ph.D., of Duke University used the Health and Retirement Study to follow a cohort of near elderly from 1992 to 1994 to examine changes in their public and private health insurance status. More than 80 percent of these individuals did not change insurance status over the 2-year period. Of those who did, many moved from private group coverage to having no insurance, and a roughly equal number did the reverse.

For more information, see "Life transitions and health insurance coverage of the near elderly," by Drs. Sloan and Conover, in Medical Care 36(2), pp. 110-125, 1998.

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Elderly Health/Long-term Care

Studies examine health care needs and access to care for people age 80 and older

In 1900, a person could expect to live to be 47. Today, there are 7.5 million individuals in the United States who are 80 years of age or older. Census Bureau estimates predict that by the year 2020 the Nation's 80-and-over population will increase by almost 75 percent to 13 million.

Individuals 80 and over are vulnerable to functional and cognitive declines from chronic disease and to acute events that can lead to hospitalization and/or institutionalization. Although the vast majority continue to live in the community, the proportion who report limitations in activities of daily living (ADLs) climbs rapidly after age 80. Up to 70 percent of this group has at least two coexisting chronic conditions, such as arthritis and diabetes. As a result, they serve as a sentinel population for the overall quality of geriatric care.

The 80+ Project, led by John Wasson, M.D., of Dartmouth Medical School, was designed to gather essential data on this growing population in order to give providers the information they need to improve the quality of care. Two recent articles by Arlene Bierman, M.D., M.S., of the Agency for Health Care Policy and Research, and her colleagues describe the needs for and barriers to care for people 80 and older as identified by the Project's telephone survey of 834 randomly selected patients and a followup mail survey of 636 respondents ages 80 and older from two integrated New England health systems in 1996. A third article describes some potential solutions for improving care and access to care for the Nation's 80-and-over population.

Patterson, J.A., Bierman, A., Splaine, M., and others (1998). "The population of people age 80 and older: A sentinel group for understanding the future of health care in the U.S." Journal of Ambulatory Care Management 21(3), pp. 10-16.

The 80+ Project surveyed respondents' health and functional status, use of health services, satisfaction with care, access to care, physical and social environment, and demographics. The data illustrate the many potential challenges encountered in managing the care of very old adults. Almost half (48 percent) reported significant limitation of physical activities. About 31 percent of respondents had been hospitalized in the past year. Fifty-four percent of respondents reported having no advance care plan, and 35 percent reported that they had not received pneumococcal vaccination.

Unfortunately, 37 percent of the very old felt that their clinician was unaware of their physical limitations; this figure increased to 42 percent for emotional needs and 76 percent for social needs. It is not surprising that 50 percent of those surveyed felt that their care could be improved.

The researchers hope that clinicians will link survey information to necessary organizational, educational, and clinical quality improvement efforts.

Reprints (AHCPR Publication No. 98-R075) are available from the AHCPR Publications Clearinghouse.

Bierman, A., Magari, E.S., Jette, A.M., and others (1998). "Assessing access as a first step towards improving the quality of care for the very old." Journal of Ambulatory Care Management 21(3), pp. 17-26.

Targeted interventions in the elderly can improve function, prevent hospitalization, and avert the need for institutionalization. However, access to effective care is a prerequisite for receiving these services. The presence of contacts with the health care system does not assure that health needs are adequately addressed. In addition to assessing financial and structural barriers to receiving any care, the authors also examined the extent to which health system encounters addressed patients' needs.

In general, respondents to the 80+ Project survey had frequent contact with the health care system; 93 percent had seen a doctor in the last 6 months, one in five had been hospitalized in the preceding 6 months, and a similar number had used home health services. Although 97 percent of respondents had a regular doctor, who was a generalist for most (89 percent), 10 percent reported trouble getting care or had delayed care because of cost, and 22 percent reported structural barriers to care (getting an appointment, advice after hours, seeing a specialist). Of the 25 percent who reported having at least one of nine common geriatric problems often or always, 23 percent reported that they had not received treatment for them.

Those reporting financial difficulty (24 percent) or ADL limitations (25 percent) also had frequent contact with the health care system. However, they were more likely to encounter barriers to care than other same-age individuals. Individuals reporting financial difficulties were eight times more likely to delay care because of cost, twice as likely to encounter structural barriers to care, and three times as likely to be unsure that their physician "could figure out what was wrong" compared with individuals reporting no financial difficulty. Individuals with ADL limitations also were significantly more likely to delay care, encounter barriers to care, and have less confidence in their physicians.

Having health insurance, a regular source of care, and a generalist physician as a primary provider were necessary but not sufficient to assure access to effective care among the very old. The authors conclude that improving health outcomes in very old adults will require interventions to reduce financial and structural barriers to care and to assure that providers have the requisite knowledge and skills to address their special needs. Furthermore, the increased attention being paid to health care quality presents an opportunity to encourage the routine assessment of access to effective care as an integral component of quality improvement efforts.

Reprints (AHCPR Publication No. 98-R076) are available from the AHCPR Publications Clearinghouse.

Splaine, M., Bierman, A.S., and Wasson, J.H. (1998). "Implementing a strategy for improving care: Lessons from studying those age 80 and older in a health system." Journal of Ambulatory Care Management 21(3), pp. 56-59.

According to the authors, improvements in health care will be facilitated and made durable when they are linked to a change in attitude from the "inside out." They describe how an "inside out" model for viewing health care from the perspective of patients and providers, placing the provider in a proactive rather than reactive role, can be adopted by physician practices. By focusing attention on the outcomes or value a patient is experiencing, providers are challenged to consider new ways of managing care.

In order to use an "inside out" approach to measure and improve care, clinicians need to understand how to optimize the smallest unit of interaction seen in a small office practice. By focusing on the steps involved in taking care of a patient, it is possible to uncover aspects of these steps that work well and those that do not. Three main challenges are faced: first, one aspect of care should be selected as the focus for improvement; second, a measurement method must be chosen (i.e., how will improvement be identified?); and third, change must be implemented into the practice.

Once a specific area with measurable objectives is selected for improvement, each person in the practice with a role would list on paper each decision made and action taken to manage typical 80-and-over patients' chronic and preventive problems during a followup visit. The measurement approach would focus on quality objectives and likely causes for failure. Finally, a implementation schedule would be started and its progress reviewed and reassessed in 4 to 6 weeks to make needed adjustments in the process.

While acknowledging multiple challenges, the authors suggest that when the "inside out" model of care is properly designed and implemented, it can result in a balanced assessment of outcomes that matter to patients, education and feedback to patients and providers, monitoring of the processes of care, ongoing measurement, and a process for designing and testing changes in care.

Reprints (AHCPR Publication No. 98-R077) are available from the AHCPR Publications Clearinghouse.

New MEPS data show changing nursing home market

Nearly one in five nursing homes offers care for residents with Alzheimer's disease or other special-need residents in specialized units, according to initial data from the Agency for Health Care Policy and Research's Medical Expenditure Panel Survey (MEPS). Just over 19 percent of all nursing homes—3,240 facilities—had one or more special-needs nursing units as of January 1, 1996, with over half of these units reserved for residents with Alzheimer's disease or related dementia. Nearly 13 percent of nursing homes, or 2,130 homes, had units for residents with Alzheimer's, and the average Alzheimer's unit housed approximately 34 beds.

Because of the dramatic growth in the number of Americans over age 75, the current nursing home population is more frail than ever before and requires more specialized care. Almost half (47.7 percent) of all nursing home residents have some form of dementia. Although data for recent years are not strictly comparable, the number of beds in formal Alzheimer's units in 1996 appears to indicate a continuation of the recent pattern of 15- to 20-percent annual increases in the number of such beds. The remaining special care nursing units are for people who need subacute care (such as those discharged from hospitals but not fully recovered), as well as those on ventilators, in need of rehabilitation, or terminally ill.

Based on initial MEPS data, AHCPR also estimates that as of January 1, 1996, nearly 1.6 million people were receiving care in approximately 16,800 nursing homes, and almost 1.8 million certified or licensed beds were available. The occupancy rate for nursing homes as a whole was roughly 89 percent.

A comparison of the 1996 MEPS data with statistics for similar facilities from AHCPR's 1987 National Medical Expenditure Survey indicates that the number of nursing homes has increased by 20 percent in almost a decade and that the number of nursing home beds has risen 19 percent. Most of the increase in the number of nursing homes resulted from a rise in the number of for-profit nursing homes affiliated with a chain (up 20 percent) and from the growth of nonprofit independent nursing homes (up 48 percent). This comparison includes facilities certified by Medicaid and/or Medicare or licensed by the State as nursing homes and providing 24-hour nursing care. The survey also found that in 1996:

• The 120,400 beds in special nursing units represented 6.9 percent of all nursing home beds.
• Nearly two-thirds of nursing homes operated for profit, and about 68 percent of these for-profit homes—or 45 percent of all nursing homes—were part of a chain.
• Nursing home residents experienced a high degree of functional difficulty. About 83 percent required assistance with three or more activities of daily living, such as bathing, eating, and using the toilet.
• Nonprofit and government-owned nursing homes were more likely than for-profit nursing homes to provide or be affiliated with non-nursing units, such as personal care or independent living. In addition, nonprofit and government-owned nursing homes were more likely to be hospital-based than for-profit nursing homes.
• Only 58 percent of nursing home residents had some type of advance directive, in the form of a living will, do-not-resuscitate order, do-not-hospitalize order, or other directive with regard to feeding, medication, or treatment.

These estimates are based on Round 1 data for 1996 collected in the MEPS Nursing Home Component. AHCPR has released public use data files for these Round 1 data and soon will publish detailed analyses of topics such as facility characteristics, special care units, and resident characteristics. Later this year AHCPR will publish full-year nursing home data for 1996, and in 1999, the Agency will publish detailed analyses of specific topics, including functional health status of residents at selected points in time; residents' use of inpatient hospital and physician services and prescription medicines; and use, expenditures, and sources of payment for nursing home care.

Copies of Nursing Home Update—1996, MEPS Highlights No. 2, (AHCPR Publication No. 97-0036) and MEPS Research Findings No. 4 (AHCPR Publication No. 98-0006), which also contains information about the Nursing Home Component, are available from the AHCPR Publications Clearinghouse.

Select for information about the survey or to access the public use data files.

Use of advance care plans increases among nursing home residents

By 1993, growing numbers and a more diverse group of nursing home residents were using advance care plans in response to the 1991 Patient Self-Determination Act (PSDA). This law requires nursing homes to inform residents of their right to participate in medical decisions and to use advance care plans to outline future medical interventions in the event they become incompetent. However, some nursing homes appear to be more willing and able to address the PSDA mandates than others, shows a study supported in part by the Agency for Health Care Policy and Research (National Research Service Award training grant T32 HS00011).

Nicholas G. Castle, Ph.D., of AtlantiCare Health Systems, and Vincent Mor, Ph.D., of Brown University, merged 1990 and 1993 data from the Health Care Financing Administration with 1991 and 1994 Medicare/Medicaid Automated Certification Survey data on 4,215 residents at 268 nursing homes to identify resident and organizational factors associated with use of advance care plans before and after implementation of the PSDA. Results showed that in 1990 (pre-PSDA), 32 percent of residents had do-not-resuscitate (DNR) status, 2 percent had do-not-hospitalize (DNH) status, and 5 percent used living wills. By 1993 (post-PSDA), 51 percent of residents had DNR status, 4 percent had DNH status, and 14 percent used living wills. In general, residents with DNR orders were a more heterogeneous group in 1993 than in 1990.

Use of advance care plans did not depend entirely on the residents' health status or preferences. Facility characteristics also played a role. In general, advance care plans were used more frequently in nursing homes with more staff and less often in homes with a greater number of Medicaid patients. Medium Medicaid census and for-profit ownership decreased the magnitude of using DNH orders by 73 percent and 54 percent, respectively, from 1990 to 1993. Also, for-profit ownership decreased the magnitude of using living wills from 1990 to 1993 by 67 percent. These findings may reflect facilities' concerns about costs.

Details are in "Advance care planning in nursing homes: Pre- and post-Patient Self-Determination Act," by Drs. Castle and Mor, in the April 1998 Health Services Research 33(1), pp. 101-124.

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Clinical Decisionmaking

AHCPR-funded study shows how doctors can safely discharge hospitalized pneumonia patients sooner

Many Americans hospitalized for community-acquired pneumonia may be able to go home sooner without adding any risk to their health under new guidelines developed by researchers supported by the Agency for Health Care Policy and Research (HS06468). The study was conducted by the Pneumonia Patient Outcomes Research Team (PORT), led by Wishwa N. Kapoor, M.D., M.P.H., of the University of Pittsburgh.

More than 1 million people are hospitalized for pneumonia each year at a cost of $9 billion. These evidence-based guidelines help doctors know when pneumonia patients reach clinical stability—defined by stable vital signs, mental status, and the ability to maintain oral intake—and could help save money by shortening hospital stays. According to the researchers, most serious events that would require intensive care (such as infection, shock, or respiratory failure) occur on the first day of hospitalization; after the first day, the risk drops dramatically. The guidelines provide scientific evidence regarding how long it takes for low-, medium-, and high-risk pneumonia patients to become stable enough to be discharged and treated as outpatients. The study found that between 65 to 85 percent of patients stayed in the hospital at least 1 day longer after reaching stability. Projections suggest that adhering to the guidelines would allow patients to be discharged sooner with a chance of serious outcomes of less than 1 percent.

According to the study's lead author, Ethan Halm, M.D., M.P.H., of Mt. Sinai School of Medicine, traditional teaching does not answer questions about how long a patient being treated for pneumonia should stay in the hospital or when he or she can be switched from intravenous antibiotics to oral medications. Different hospitals may keep patients hospitalized for 1 week or more or send them home in just 1 day, with neither option using scientific criteria. Dr. Halm says that practicing more evidence-based medicine will, on average, decrease the hospital length of stay for most patients without compromising their health and safety. It also will reduce the risk of sending sicker patients home too quickly. Using the new guidelines' stability indicators means that each patient will stay in the hospital the right amount of time according to objective criteria.

For more information, see "Time to clinical stability in patients hospitalized with community-acquired pneumonia," by Dr. Halm, Michael J. Fine, M.D., M.Sc., Thomas J. Marrie, M.D., and others, in the May 13, 1998, Journal of the American Medical Association 279(18), pp. 1452-1457.

Quinolone antibiotics reduce infections in cancer patients undergoing chemotherapy

Infections remain an important problem for patients undergoing intensive chemotherapy for cancer. Although improvements in infection management have substantially decreased mortality from the high rates noted in the 1960s and 1970s, continued infection-related illness has prompted the search for effective prophylaxis.

Prophylaxis with quinolone antibiotics dramatically reduces the occurrence of some types of infections that plague patients undergoing intensive cancer chemotherapy, concludes a study supported by the Agency for Health Care Policy and Research (HS07782 and National Research Service Award training grant T32 HS00060). Interestingly, however, while patients who received these oral antibiotics had about half as many infections overall as those who did not receive prophylaxis, many patients still developed fevers and had to receive intravenous antibiotics. Also, prophylaxis did not reduce mortality. The ultimate utility of prophylaxis therefore remains uncertain, according to the New England Medical Center researchers who conducted the study, and further work is needed to determine the most appropriate ways to prevent infection in cancer patients.

The researchers performed a meta-analysis of 18 clinical trials involving 1,408 cancer patients who were undergoing chemotherapy. Compared with those who received no prophylactic antibiotics, patients who received quinolones experienced 79 percent fewer gram-negative infections and 77 percent fewer gram-negative bacteremias; a substantial number of patients had more than one type of infection. The reduction in gram-negative infections translated into 46 percent fewer total infections. Results were similar for trials that used trimethoprim/sulfamethoxazole (TMS) prophylaxis as the control regimen.

There has been some concern that by eliminating some of the normal bacterial flora, quinolones could predispose patients to infections with other species. This study showed that the incidence of quinolone-resistant infections was not higher among quinolone recipients than controls. However, continued vigilance is warranted, note the researchers. Because prophylaxis with currently available quinolones does not reduce the risk of gram-positive bacterial infections, which are becoming the most common infections in these patients, new regimens that prevent gram-positive infections may be of benefit.

See "Efficacy of quinolone prophylaxis in neutropenic cancer patients: A meta-analysis," by Eric A. Engels, M.D., M.P.H., Joseph Lau, M.D., and Michael Barza, M.D., in the March 1998 Journal of Clinical Oncology 16(3), pp. 1179-1187.

NSAIDs and muscle relaxants are often used to treat back pain in primary care

Primary care physicians typically prescribe nonsteroidal antiinflammatory drugs (NSAIDs, such as aspirin and ibuprofen), often augmented by muscle relaxants, for back pain patients. Patients prescribed this combination of medications report significantly less pain 1 week later than those not receiving medications and somewhat less pain than those receiving other medications, concludes a study conducted by the Low Back Pain Patient Outcomes Research Team (PORT) and supported by the Agency for Health Care Policy and Research (HS06344 and HS08194).

This exploratory study offers evidence for a possible benefit of muscle relaxants either alone or in combination with NSAIDs, according to the PORT's co-principal investigator Daniel C. Cherkin, Ph.D., of the Group Health Cooperative of Puget Sound in Seattle. The researchers interviewed 219 patients 20 to 69 years of age who were members of a large health maintenance organization (HMO) and were making their first doctor visit for an episode of back pain. The patients filled out questionnaires on sociodemographic characteristics, health status, back pain experience, and use of medications. The researchers then contacted the patients by telephone to assess symptom severity and dysfunction at 1, 3, and 7 weeks after the visit.

Results showed that 69 percent of patients were prescribed NSAIDs, 35 percent muscle relaxants,

12 percent narcotic analgesics such as codeine, and 4 percent acetaminophen (a nonnarcotic analgesic); 20 percent received no medications. Almost one-third of patients receiving any medications were prescribed both muscle relaxants and NSAIDs, and this group had the best outcomes. The researchers call for randomized controlled trials to determine which medications or combinations of medications are most effective.

See "Medication use for low back pain in primary care," by Dr. Cherkin, Kimberly J. Wheeler, Ph.D., William Barlow, Ph.D., and Richard A. Deyo, M.D., M.P.H., in Spine 23(5), pp. 607-614, 1998.

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