Report: Evidence-based care for elderly varies widely

Some aging patients spend nearly a month of the year in contact with the healthcare system, whether in the hospital, at a doctor’s office or at a lab visit, but still might not be receiving medical care that reflects evidence-based practices, according to a report from the Dartmouth Atlas Project.

The report, “Our Parents, Ourselves: Health Care for an Aging Population,” serves as a report card showing where the U.S. is making progress in patient-centered care and where improvements need to be made for older adults, a population predicted to jump from 43.1 million in 2012 to 83.7 million by 2050.

The report highlights areas of healthcare that present distinctive challenges faced by older adults, including those with multiple chronic conditions or dementia.

“It is striking how much of an older adult’s life is occupied by healthcare, especially those with multiple chronic conditions or dementia,” Julie P.W. Bynum, MD, MPH, associate professor of the Dartmouth Institute for Health Policy & Clinical Practice and the report’s lead author, said in a release. “In 2012, the average Medicare beneficiary was in contact with the healthcare system on 17 days—meaning in an inpatient setting or having a clinician visit, procedure, imaging study or lab tests in an outpatient setting—and 33 days if they had two or more chronic conditions.”

Highlighting geographic disparities, the report noted Medicare beneficiaries in East Long Island and Manhattan, N.Y., spent 24.9 and 24.6 days, respectively, in contact with the healthcare system, while patients in Marquette, Mich., and Lebanon, N.H., only spent 10.3 and 10.2 days, respectively.

For patients with multiple chronic conditions and dementia, the amount of time spent in contact with the healthcare system was even higher. Across the 306 hospital referral regions the report looked at, patients in Manhattan and East Long Island, N.Y., tied for the highest rate of contact days among patients with two or more chronic conditions, at 46.2 days, and patients in East Long Island also had the highest rate of contact days among patients with dementia, at 44.9 days.

“The findings from this report will generate meaningful conversation about the care for our aging population and identify areas of action for health systems, advocates and policy makers,” said Terry Fulmer, PhD, RN, FAAN, president of The John A. Hartford Foundation, which sponsored the report. “This action is especially needed for older adults with multiple chronic conditions or dementia who often face complex challenges when navigating the healthcare system and advocating for the best care possible.”

The report also sheds light on the fact that, on average, just more than half (56.9 percent) of Medicare beneficiaries in 2012 had a primary care physician as their predominant provider of care—the doctor with whom the person has the most outpatient visits—despite evidence suggesting that greater reliance on primary care physicians can lower costs and reduce avoidable hospitalizations.

In addition to these broad measurements based on 2012 Medicare data, the report looks at whether patients are receiving medical treatments in accordance with evidenced-based practices.

Among the starkest findings is the lack of adherence to guidelines for prostate cancer screening with a blood test, called a prostate-specific antigen (PSA) test. Although once debated, the US Preventive Services Task Force (USPSTF) in 2012 recommended against all PSA screening regardless of age. The American Cancer Society and the American Urological Association recommend against PSA testing in older men, but recommend that younger men should practice shared-decision making with their doctors to discuss the pros and cons. Despite these recommendations, the national average rate of PSA screening among older men, ages 75 and older, was 19.5 percent, and regional discrepancies were significant, from 9.9 percent in Casper, Wyo., to 30 percent in Miami, Fla.

Similarly, regular breast cancer screening with mammography has long been promoted in the medical community, but the cost-benefit analysis shifts for the elderly. The USPSTF recommends biennial screening mammography for women ages 50-74, but notes that there is insufficient evidence to assess the benefits of screening in women 75 years and older, and evidence has shown the potential harmful effects of false positive results. Despite these findings, the report indicates that the national average rate of screening mammography for women age 75 and older was 24.2 percent, but rates varied more than twofold across hospital referral regions, from 15.3 percent in Miami, Fla., to 37.2 percent in Sun City, Ariz.

The report also offers a historical look at where continued monitoring of key practices and measures has led to improvements in recent years, such as a more than 10 percent increase in adherence to diabetes testing guidelines, when comparing data from 2003-05 and 2012.

Among the most striking improvements were preventable hospital admissions which declined 23 percent, from 5.5 percent of Medicare beneficiaries in 2003 to 4.2 percent in 2012. Rates declined in nearly every hospital referral region, but they varied more than threefold, from 2.2 percent in San Mateo County and San Luis Obispo, Calif., to 7.3 percent in Monroe, La.

The report also looks at 30-day readmission rates, annual wellness visit rates and the number of unique clinicians that patients see on average, as well as end-of-life treatments, such as late hospice referral and the number of days spent in intensive care, among other findings.

Access the full report.