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 Women’s 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 Women’s 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 Women’s 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