Diabetes Quality of Care among Nursing Home New Admission Cohort

1. Diabetes Quality of Care among Nursing Home New Admission Cohort Charlene C. Quinn, RN, PhD Assistant Professor University of Maryland School of Medicine Division of Gerontology Funded by National Institute on Aging (RO1 AG08221; R29 AG11407)

2. Presentation Objective: Describe diabetes care and utilization in nursing home cohort • Significance/Study Rationale • Methods • Results • Secondary prevention procedures use • Identify adverse outcomes • Findings by dementia status • Relevance to practice and policy

3. Significance • Diabetes affects 20% of all older adults, higher rates for minorities • Expenditures attributable to diabetes estimated at $132 billion • Nursing home care (15.1%) one of major expenditure groups • Eliminating or reducing problems caused by diabetes could improve quality of life and reduce expenditures

4. Study Rationale • Diabetes is common in the long-term care setting • Strong evidence for comprehensive monitoring reduces or slows diabetes complications • Management of diabetes may be complicated by dementia status

5. Study Questions • What are the characteristics of diabetic nursing home residents? • What secondary prevention procedures are diabetics receiving prior to and during the nursing home stay? • What diabetic complications are occurring pre- and post-admission to a nursing home? • Is there a dementia effect?

6. Method • “Epidemiology of Dementia in Nursing Homes” • Cohort study of 2285 new admissions to 59 nursing homes (NH) in Maryland • Patients assessed at admission (1992-1995), expert panel determined dementia status • Residents followed 2 years after admission • Medical chart, MDS

7. Method • Linked Medicare and Medicaid claims data to subjects in parent study • Diabetes identified by admission MDS, n=404 (17.7% of sample) • Medicare records indicating any secondary prevention procedures by CPT codes

8. Method • Medicare records for patient complications for inpatient and outpatient encounters in five categories determined by ICD-9 codes: • Diabetes • Dehydration • Macro- and micro-vascular events • Metabolic complications • Infection complications

9. Selected Sample Characteristics(N=404) No dementia vs. dementia: ***p<.001, **p<.01, *p<.05

10. Selected Sample Characteristics(N=404) No dementia vs. dementia: ***p<.001, **p<.01, *p<.05

11. Secondary Prevention Procedures, Period 6 months prior to NH admission No dementia vs. dementia: ***p<.001, **p<.01, *p<.05 n=404, unadjusted

12. Secondary Prevention Procedures,Period NH admission through 6 months No dementia vs. dementia: ***p<.001, **p<.01, *p<.05 N=404, unadjusted

13. Secondary Prevention Procedures,NH placement (all diabetics) Time effect: ***p<.001, **p<.01, *p<.05 N=404, unadjusted

14. Hospitalizations for Patient Complications N=404, unadjusted No dementia vs. dementia: *p<.05 Time trend *p<.05

15. Summary • Rate of diabetes in new admissions to statewide sample of 59 NHs is 18%. • Person with diabetes and dementia • Older age • More likely non-white • Have longer NH lengths of stay • Incur lower Medicare costs before nursing home admission (HCC) • Less likely to be a Medicare qualified stay • More likely Medicaid eligible at admission

16. Summary • In the 6-month period prior to NH admission, diabetics with dementia are less likely to receive secondary prevention procedures. • In the first 6 months of NH admission, all diabetics, regardless of dementia status, are more likely to receive secondary prevention procedures, except for HbA1c and eye exams. • For diabetics with dementia, it appears the NH admission is providing a “process” for diabetics to receive diabetes management

17. Summary • Hospitalizations resulting from 5 major groups of complications are similar between dementia and non-dementia groups • Higher rates of overall hospitalization post-NH admission for those without dementia reflects higher pre-NH admission rates of hospitalization • Micro- and macro-vascular hospitalizations increase slightly post-NH admission (time p=.042, adjusting for demographics, comorbidities, NH LOS)

18. Relevance to Practice and Policy • Nursing homes are caring for a large number of older persons with diabetes and are providing secondary prevention procedures to prevent or delay diabetes complications • Increased importance among current NH environment with much shorter NH LOS (27 days) • Identify with patients and families important secondary procedures (eye exams, HbA1c) • Increasing prevalence of diabetes will increase number of persons admitted to NHs with diabetes and comorbidities

19. Relevance to Practice and Policy • Intensive treatment for all diabetics in the long-term care setting may not be appropriate • Managing diabetes for potential complications may impact Medicare utilization and costs

20. Co-Investigators Jay Magaziner Kenneth Boockvar Bruce Stuart J. Richard Hebel Ann Gruber-Baldini Verita Custis Buie Conrad May Ajith Silva Lynda Burton Steve Kittner Ilene Zuckerman Van Doren Hsu Sheryl Zimmerman