Progress in Caring for Older Patients?

Throughout the United States, there have been dynamic changes in healthcare technology, healthcare delivery, and health behaviors in recent years. There has been a push to improve healthcare quality on the national level by creating measures to reduce medical errors and increase hospital safety. Public reporting on hospital performance and efforts to improve continuity of care have also been significant initiatives. “Much focus is often directed to finding deficiencies in healthcare so that we can work on them,” says Harlan M. Krumholz, MD, MS. “Unfortunately, this can lead people to perceive that our healthcare system is broken or ineffective.”

Most studies that have been published in the past tend to explore trends in healthcare based on specific disease states, but research is lacking on how medical care is progressing overall. One way to broaden the knowledge base is to use data from the Medicare fee-for-service program of CMS. “This data provides information on trends in mortality, hospitalizations, and outcomes relating to a variety of health issues,” says Dr. Krumholz. “By analyzing national hospital trends in the Medicare population, we can see if national quality improvement efforts have been paying off. Ultimately, this data can help us look at past performance and develop targets for future interventions.”

Long-Term Trends

For a study published in JAMA, Dr. Krumholz and colleagues assessed trends among Medicare beneficiaries aged 65 and older from 1999 through 2013. This included data from patients enrolled in fee-for-service and Medicare Advantage, the managed care component of Medicare. The investigation looked at mortality, hospitalization rates, and hospitalization-associated outcomes and expenditures. In addition, the study evaluated trends in hospitalizations, costs, and dispositions in the last 1, 3, and 6 months of life in the fee-for-service program.

In total, the study sample consisted of more than 68 million unique Medicare beneficiaries. All-cause mortality for all Medicare beneficiaries declined from approximately 5.3% in 1999 to about 4. 5% in 2013 (Figure), and death rates decreased for inpatients and outpatients. The number of hospitalizations also decreased from more than 35,000 per 100,000 person-years annually to less than 27,000 per 100,000 person-years. Inpatient spending decreased from about $3,300 per person in 1999 to $2,800 in 2013 after adjusting for inflation.

“There was about a 24% decline in overall hospitalization rates among the Medicare population,” Dr. Krumholz says. “This decrease also helped reduce expenses and improve patient outcomes. Among individuals who were hospitalized, we saw about a 30% improvement in survival.” These declines were consistent across geographic and demographic groups throughout the study period. The research team noted that many of the worst-performing geographic regions in 2013 performed at a higher level than the best-performing regions in 1999.

The study also found that the number of hospitalizations decreased from 131.1 to 102.9 per 100 deaths among fee-for-service beneficiaries in the last 6 months of life over the study period. By 2013, more patients were being discharged to skilled nursing facilities, long-term care facilities, hospice, or home health services than in 1999. Additionally, fewer older patients were being sent home without health services.

Possible Explanations

There are many possible explanations for the findings, according to Dr. Krumholz. For example, improvements may be partly associated with national efforts to improve care for all patients across the study period. The management of chronic health conditions like hypertension, diabetes, and cardiovascular disease has improved in recent years. The findings may also be a reflection of patients living healthier lives. While obesity continues to be a problem, many Americans are quitting smoking and living more active lifestyles.

Recent technological advances and changes in trends of people enrolling in fee-for-service Medicare versus Medicare Advantage may have also influenced the findings. “It’s difficult to disentangle the specific reasons for improvement, but it’s clear that there have been marked reductions in mortality, hospitalization, and adverse hospital outcomes among Medicare patients aged 65 and older over the past 15 years,” Dr. Krumholz says. “A significant amount of money has been spent on healthcare improvement, but these efforts are helping increase life expectancy and enhancing the health of older individuals.”

Avoid Complacency

Dr. Krumholz notes that the trends observed in the study were truly remarkable and demonstrate a gradual improvement over time. However, he cautions that more work is necessary. “Our findings should serve as a call to action to embrace healthcare evolution,” he says. “We should have some confidence that we’re heading in the right direction, but we shouldn’t become complacent. We’re clearly making strides, but we should recognize the importance of quality of care and remain vigilant about continuing to raise the bar.”