Established relationships with doctors and other healthcare professionals can improve outcomes and lower medical bills for people with Alzheimer’s disease and other forms of dementia, according to a new study.
Dartmouth Institute for Health Policy and Clinical Practice professor Julie Bynum served as senior author of the study. “People with Alzheimer’s and dementia are a pretty unique population of older adults that face challenges of getting coordinated care,” said Bynum.
Alzheimer’s disease and other dementia are complex, expensive illnesses. Alzheimer’s is the most common form of dementia in people over the age of 65. Currently, upwards of 5 million people in the United States age 65 and older may have Alzheimer’s disease, according to the National Institutes of Health (NIH). Alzheimer’s disease is only one form of dementia, however, and 20 to 40 percent of those with one type of dementia have another form of the disorder.
Understanding the association between continuity of care and outcomes for seniors with dementia is becoming increasingly important, as the number of people living with the cognitive disorder could double within the next 40 years as the population ages. NIH expects the number of senior citizens to rise from 40 million today to more than 88 million by 2050. Age is the primary risk factor for developing dementia, but age is also the primary risk for a large number of minor and serious illnesses that require medical attention.
Dementia places extra socioeconomic burdens on seniors; it can also reduce quality of care.
Older patients often see several physicians each year for treatment for various conditions unrelated to dementia. In fact, the typical person over the age of 65 has seen an average of 28.4 doctors over the course of their lifetime, including primary care providers, specialists, hospital and urgent care providers. Each time an elderly patient sees a new doctor, she carries a burden of relaying her medical history and symptoms to that practitioner. This can be difficult for a patient with all her faculties but nearly impossible for a patient with Alzheimer’s disease or another form of dementia.
The Study
The observational retrospective cohort study, published in the Journal of the American Medical Association Internal Medicine, included 1,416,369 continuously enrolled, fee-for-service Medicare beneficiaries aged 65 and older who were living in the community. The researchers included only those participants who had a claims-based diagnosis of dementia and four or more outpatient visits with a healthcare provider in 2012. The average age of participants was 81; 65 percent were female and 83 percent Caucasian.
The researchers measured patient visits to physicians over the course of 12 months to determine continuity of care scores. They assigned higher scores to visit patterns in which the larger share of total visits were with fewer clinicians.
Outcomes included all-cause hospitalization, emergency department visits, ambulatory care, laboratory testing including urinalysis and urine culture, imaging including computed tomography (CT) scan of the head, and healthcare spending including overall costs, payments to hospitals and skilled nursing facilities and to physicians.
The Results
Almost half of patients had at least one hospitalization and emergency department visit during the year. Medicare beneficiaries with dementia who received lower levels continuity of care were younger, had higher income, and suffered more comorbid medical conditions.
The researchers compared the groups with the highest versus the lowest continuity of care, and found that utilization was lower with higher level of continuity. Annual rates of hospitalization among patients with high levels of continuity were only 0.83 versus 0.88 for those with poor continuity of care. The annual rate of emergency department visits was also lower among those with good continuity of care, at 0.84 versus 0.99. Continuity was associated with fewer radiology and lab tests, with utilization rates of 0.71 versus 0.83 for CT scan of the head and 0.72 versus 1.09 for urinalysis. All groups showed similar rates of ambulatory care sensitive condition hospitalization.
Total healthcare spending was higher for those patients with poor continuity of care continuity, even after accounting for sociodemographic factors and the financial burden of comorbidities. Total spending for those with good continuity was $22,004, as compared with $24,371 for those with poor continuity of care.
The study demonstrates the association between lower continuity of care and higher rates of emergency department visits, testing, hospitalization, and healthcare spending.
The authors concluded the study by urging further research into the relationships between continuity of care and outcome to determine whether improving continuity of care can benefit older, fee-for-service Medicare beneficiaries with Alzheimer’s disease or dementia and other patients in the healthcare system.
Continuity of Care Lowers Costs
The total cost of care associated with dementia is an estimated $236 billion, which is about equal to or a little more than the costs of care for heart disease and cancer. Fragmented care is more expensive than continuity of care. The study reveals that the costs of fragmented care are associated with an additional $567 million to $1.1 billion in health care spending as compared with continuity of care costs.
“The findings are what we expected. If you have higher continuity you are less likely to have hospitalization, you are less likely to use the emergency room, your spending is lower,” Bynum said. “Having a tight-knit group of doctors means better outcomes for this population. We think this really suggests that having prior knowledge of a person with dementia and having that relationship improves some aspects of the care.”
Continuity of care reduces this burden as the primary care physician or other medical professional acts as the lead in providing and orchestrating care.
Improving Continuity of Care
The study provides important findings for those with Alzheimer’s disease even as efforts to find a cure for this disease and other forms of dementia continue.
The key to improving continuity of care is to begin building caregiving relationships as early as possible. Individuals with dementia can ask caregivers if they are willing to coordinate care, or choose a friend or family who can speak for them when they are unable. Family members and friends can work as advocates to relay the patient’s health history or symptoms during doctor visits can also improve care and reduce costs.
Patients and their personal care providers can improve continuity of care by reducing the number of healthcare providers they see by waiting a day or two to get into their regular doctor instead of going to an emergency department or urgent care clinic whenever possible. Working with a doctor or nurse practitioner who is familiar with the patient’s history and dementia symptoms, such as confusion and memory problems, can help to reduce frustration, avoid misunderstandings, and improve care.
“There’s tremendous efforts going into building a cure or treatment,” says Bynum. “At the same time, today we need our health care system ready and willing and able to give the best care they can to this growing population.”
