1. Diabetes Quality of Care among Nursing Home New Admission Cohort Charlene C. Quinn, RN, PhD Assistant Professor University of Maryland School of Medicine Division of Gerontology Funded by National Institute on Aging (RO1 AG08221; R29 AG11407)

2. Presentation Objective: Describe diabetes care and utilization in nursing home cohort Significance/Study Rationale Methods Results –Secondary prevention procedures use –Identify adverse outcomes –Findings by dementia status Relevance to practice and policy

3. Significance Diabetes affects 20% of all older adults, higher rates for minorities Expenditures attributable to diabetes estimated at $132 billion Nursing home care (15.1%) one of major expenditure groups Eliminating or reducing problems caused by diabetes could improve quality of life and reduce expenditures

4. Study Rationale Diabetes is common in the long-term care setting Strong evidence for comprehensive monitoring reduces or slows diabetes complications Management of diabetes may be complicated by dementia status

5. Study Questions What are the characteristics of diabetic nursing home residents? What secondary prevention procedures are diabetics receiving prior to and during the nursing home stay? What diabetic complications are occurring pre- and post-admission to a nursing home? Is there a dementia effect?

6. Method Epidemiology of Dementia in Nursing Homes –Cohort study of 2285 new admissions to 59 nursing homes (NH) in Maryland –Patients assessed at admission (1992- 1995), expert panel determined dementia status –Residents followed 2 years after admission Medical chart, MDS

7. Method Linked Medicare and Medicaid claims data to subjects in parent study Diabetes identified by admission MDS, n=404 (17.7% of sample) Medicare records indicating any secondary prevention procedures by CPT codes

8. Method Medicare records for patient complications for inpatient and outpatient encounters in five categories determined by ICD-9 codes: –Diabetes –Dehydration –Macro- and micro-vascular events –Metabolic complications –Infection complications

9. Selected Sample Characteristics (N=404) CharacteristicsDementia (n=185) No dementia (n=219) Mean age79.9 78.2 * Males29.7%27.9% White67.0% 82.1% *** NH length of stay423.9 days241.3 days*** No dementia vs. dementia: ***p<.001, **p<.01, *p<.05

10. Selected Sample Characteristics (N=404) CharacteristicsDementia (n=185) No dementia (n=219) HCC (cost estimate 12mo. pre-admit) $15,240 $19,596 *** Medicaid 34.6% 24.2% * Medicare Qualified Stay 54.3% 69.7% ** No dementia vs. dementia: ***p<.001, **p<.01, *p<.05

11. Secondary Prevention Procedures, Period 6 months prior to NH admission n=404, unadjusted ProcedureDementia (%)No dementia (%) HbA1c 12.4 21.0 * Fasting plasma glucose 53.0 64.8 * Eye exam 8.1 21.5 *** Lipid profile 11.9 14.6 Serum creatinine 43.8 58.0 ** Urinalysis 20.5 30.6 * No dementia vs. dementia: ***p<.001, **p<.01, *p<.05

12. Secondary Prevention Procedures, Period NH admission through 6 months ProcedureDementia (%)No dementia(%) HbA1c 11.4 14.6 Fasting plasma glucose 84.3 84.0 Eye exam 7.0 8.2 Lipid profile 21.6 25.6 Serum creatinine 80.0 80.4 Urinalysis 50.3 53.4 N=404, unadjusted No dementia vs. dementia: ***p<.001, **p<.01, *p<.05

13. Secondary Prevention Procedures, NH placement (all diabetics) ProcedurePre-admit (%) Post-admit (%) HbA1c 17.113.1 Fasting plasma glucose 59.4 84.2 *** Eye exam 15.3 7.7 Lipid profile 13.4 23.8 *** Serum creatinine 51.5 80.2 *** Urinalysis 26.0 52.0 *** N=404, unadjusted Time effect: ***p<.001, **p<.01, *p<.05

14. Hospitalizations for Patient Complications N=404, unadjusted 6 months Pre-admit6 months Post-admit Complication Dementia % No Dementia % Dementia % No Dementia % Dehydration 16.217.411.98.7 Micro/macro events 4.9 9.1 5.9 9.6 * Metabolic 3.8 3.7 2.7 0.9 Infections 19.519.6 11.915.1 Diabetes Overall hosp. 39.5 51.6 * 17.3 27.9 * No dementia vs. dementia: *p<.05 Time trend *p<.05

15. Summary Rate of diabetes in new admissions to statewide sample of 59 NHs is 18%. Person with diabetes and dementia –Older age –More likely non-white –Have longer NH lengths of stay –Incur lower Medicare costs before nursing home admission (HCC) –Less likely to be a Medicare qualified stay –More likely Medicaid eligible at admission

16. Summary In the 6-month period prior to NH admission, diabetics with dementia are less likely to receive secondary prevention procedures. In the first 6 months of NH admission, all diabetics, regardless of dementia status, are more likely to receive secondary prevention procedures, except for HbA1c and eye exams. –For diabetics with dementia, it appears the NH admission is providing a process for diabetics to receive diabetes management

17. Summary Hospitalizations resulting from 5 major groups of complications are similar between dementia and non-dementia groups –Higher rates of overall hospitalization post-NH admission for those without dementia reflects higher pre-NH admission rates of hospitalization –Micro- and macro-vascular hospitalizations increase slightly post-NH admission (time p=.042, adjusting for demographics, comorbidities, NH LOS)

18. Relevance to Practice and Policy Nursing homes are caring for a large number of older persons with diabetes and are providing secondary prevention procedures to prevent or delay diabetes complications –Increased importance among current NH environment with much shorter NH LOS (27 days) –Identify with patients and families important secondary procedures (eye exams, HbA1c) –Increasing prevalence of diabetes will increase number of persons admitted to NHs with diabetes and comorbidities

19. Relevance to Practice and Policy Intensive treatment for all diabetics in the long-term care setting may not be appropriate Managing diabetes for potential complications may impact Medicare utilization and costs

20. Co-Investigators Jay MagazinerKenneth Boockvar Bruce StuartJ. Richard Hebel Ann Gruber-BaldiniVerita Custis Buie Conrad MayAjith Silva Lynda BurtonSteve Kittner Ilene Zuckerman Van Doren Hsu Sheryl Zimmerman