Greysen S Ryan, Stijacic Cenzer Irena, Boscardin W John, Covinsky Kenneth E
Section of Hospital Medicine, Division of General Internal Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
Division of Geriatric Medicine, University of California, San Francisco, California.
J Am Geriatr Soc. 2017 Sep;65(9):1996-2002. doi: 10.1111/jgs.14955. Epub 2017 Jun 21.
To assess the effects of preadmission functional impairment on Medicare costs of postacute care up to 365 days after hospital discharge.
Longitudinal cohort study.
Health and Retirement Study (HRS).
Nationally representative sample of 16,673 Medicare hospitalizations of 8,559 community-dwelling older adults from 2000 to 2012.
The main outcome was total Medicare costs in the year after hospital discharge, assessed according to Medicare claims data. The main predictor was functional impairment (level of difficulty or dependence in activities of daily living (ADLs)), determined from HRS interview preceding hospitalization. Multivariable linear regression was performed, adjusted for age, race, sex, income, net worth, and comorbidities, with clustering at the individual level to characterize the association between functional impairment and costs of postacute care.
Unadjusted mean Medicare costs for 1 year after discharge increased with severity of impairment in a dose-response fashion (P < .001 for trend); 68% had no functional impairment ($25,931), 17% had difficulty with one ADL ($32,501), 7% had dependency in one ADL ($39,928), and 8% had dependency in two or more ADLs ($45,895). The most severely impaired participants cost 77% more than those with no impairment; adjusted analyses showed attenuated effect size (33% more) but no change in trend. Considering costs attributable to comorbidities, only three conditions were more expensive than severe functional impairment (lymphoma, metastatic cancer, paralysis).
Functional impairment is associated with greater Medicare costs for postacute care and may be an unmeasured but important marker of long-term costs that cuts across conditions.
评估入院前功能障碍对出院后长达365天的医保后期护理费用的影响。
纵向队列研究。
健康与退休研究（HRS）。
2000年至2012年全国具有代表性的8559名社区居住老年人的16673次医保住院样本。
主要结局是出院后一年的医保总费用，根据医保理赔数据进行评估。主要预测因素是功能障碍（日常生活活动（ADL）的困难程度或依赖程度），通过住院前的HRS访谈确定。进行多变量线性回归，对年龄、种族、性别、收入、净资产和合并症进行调整，并在个体水平上进行聚类分析，以描述功能障碍与后期护理费用之间的关联。
出院后1年未调整的平均医保费用随着功能障碍严重程度呈剂量反应关系增加（趋势P <.001）；68%无功能障碍（25931美元），17%一项ADL有困难（32501美元），7%一项ADL有依赖（39928美元），8%两项或更多ADL有依赖（45895美元）。功能障碍最严重的参与者比无功能障碍者费用高77%；调整分析显示效应量减弱（高33%）但趋势无变化。考虑到合并症导致的费用，只有三种情况比严重功能障碍更昂贵（淋巴瘤、转移性癌症、瘫痪）。
功能障碍与医保后期护理费用增加有关，可能是一个未测量但跨越各种情况的长期费用的重要标志。
