Continuity of Care Key to Treating Older Adults with Dementia

Older fee-for-service Medicare beneficiaries with dementia who have lower levels of continuity of care (COC) have higher rates of hospitalization, emergency department (ED) visits, testing, and healthcare spending, according to a study in JAMA Internal Medicine.

Investigators, led by Halima Amjad, MD, MPH, of Johns Hopkins School of Medicine, studied COC at the level of the clinician because they thought it may be especially important for building clinician-patient-family relationships that address goals and expectations of care over time in patients with dementia. In other populations, higher COC has been associated with decreased hospitalization, medical procedure overuse, and cost. Greater COC may also improve patient-clinician trust, quality of communication, and patient satisfaction, factors that may help reduce barriers to high-quality care in dementia.

Amjad and colleagues studied 1,415,369 community-dwelling fee-for-service patients insured by Medicare who had a claims diagnosis of dementia, survived the year, and had 4 or more ambulatory visits in 2012. They assigned COC scores measured on patient visits across physicians over a 1-year period, and gave higher scores to visit patterns in which a larger share of the patient’s total visits are with fewer clinicians.

The outcomes that were measured were all-cause hospitalization; ED visits that did not result in inpatient hospitalization from outpatient claims; imaging and laboratory testing (with special attention to tests that may be overused in this population to evaluate changes in mental status or behavioral symptoms, such as CT of the head, chest radiography, urinalysis, and urine culture); and healthcare spending (total spending includes MedPAR, Part B claims, home health, hospice, durable medical equipment, and other facility spending).

The study found that with increasing levels of COC, age, proportions of women and nonwhites were higher, and median household income was lower. People with low COC had more chronic conditions and higher illness burden. They also had higher proportions of coronary artery disease, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD) compared with those with high COC. The low COC group had a mean of 15.6 visits to 7.1 unique clinicians, compared with 14.8 visits to 4.8 clinicians and 10.5 visits to 2.5 clinicians in the medium- and high-COC groups, respectively.

Low continuity of ambulatory care among community-dwelling older adults with a dementia diagnosis is associated with higher rates of hospitalization, ED visits, radiologic and lab testing, and greater healthcare spending, the researchers conclude. Lower COC is not associated with hospitalizations considered to represent conditions for which hospitalizations could be avoided if the patient receives timely and adequate outpatient care (such as diabetes complications, asthma, hypertension, COPD, and CHF) in this population, however.

“The overall volume of health services utilization and testing is striking, with almost half of the cohort experiencing hospitalization, and ED visit, and a CT scan of the head in the course of the year,” the authors wrote. “When considering differences in healthcare spending per beneficiary, individuals with the most fragmented care are associated with an additional $567 million to $1.1 billion in healthcare spending compared with those with medium or high continuity.”

Addressing care fragmentation could decrease hospitalizations, ED visits, unnecessary testing, and overtreatment in this at-risk population, the researchers say, and suggest clinician familiarity with patients’ cognitive and functional abilities, coexisting conditions, support systems, and goals of care as potential ways to do so.