Abstract and Introduction
Abstract
Background: Intensive care unit (ICU) utilization has increased among patients with Alzheimer disease and related dementia (ADRD), although outcomes are poor.
Objectives: To compare ICU discharge location and subsequent mortality between patients with and patients without ADRD enrolled in Medicare Advantage.
Methods: This observational study used Optum's Clinformatics Data Mart Database from years 2016 to 2019 and included adults aged >67 years with continuous Medicare Advantage coverage and a first ICU admission in 2018. Alzheimer disease and related dementia and comorbid conditions were identified from claims. Outcomes included discharge location (home vs other facilities) and mortality (within the same calendar month of discharge and within 12 months after discharge).
Results: A total of 145 342 adults met inclusion criteria; 10.5% had ADRD and were likely to be older, female, and have more comorbid conditions. Only 37.6% of patients with ADRD were discharged home versus 68.6% of patients who did not have ADRD (odds ratio [OR], 0.40; 95% CI, 0.38–0.41). Both death in the same month as discharge (19.9% vs 10.3%; OR, 1.54; 95% CI, 1.47–1.62) and death in the 12 months after discharge (50.8% vs 26.2%; OR, 1.95; 95% CI, 1.88–2.02) were twice as common among patients with ADRD.
Conclusions: Patients with ADRD have lower home discharge rates and greater mortality after an ICU stay than patients without ADRD.
Introduction
Alzheimer disease and related dementia (ADRD) affects more than 6 million Americans. That figure is expected to increase to 13.8 million by 2060, with growing individual, family, and societal burden.[1,2] Older adults living with ADRD have higher rates of emergency department and hospital visits, including higher rates of stay in the intensive care unit (ICU).[2–4] Older adults living with ADRD constitute more than 15% of ICU admissions, and their use of ICU services has more than doubled in the past 2 decades.[5–8] These critically ill patients have a higher rate of hospital-acquired complications, which can result in a rapid decline in cognitive and physical function.[9,10]
Most studies investigating outcomes such as mortality or living situation among patients with ADRD admitted to the ICU have focused on patients admitted directly from a nursing home and are often limited to Medicare fee-for-service beneficiaries. In the past decade, Medicare Advantage (MA) plans have grown substantially; 48% of Medicare beneficiaries were enrolled in such a plan in 2022, up from 19% in 2007.[11] Although we know that the prevalence of ADRD among MA plan beneficiaries has been lower than that of beneficiaries of traditional fee-for-service Medicare,[12] we know little about the status of ADRD patients enrolled in MA plans. Given that MA penetration has been steadily increasing, the MA beneficiary population is of growing interest.
In addition, historically, when an MA enrollee entered hospice care, MA plans had a "carve out" for hospice care in which traditional Medicare fee-for-service would assume responsibility for most services and the MA plan kept control of supplemental services. However, beginning in 2023, the Centers for Medicare and Medicaid Services (CMS) will evaluate the MA value-based insurance design model, an alternative to the MA carve out, in which one focus area will be the hospice benefit component.[13] In light of the growing number of MA beneficiaries, lack of knowledge about MA beneficiaries with ADRD, little research related to ICU use among MA beneficiaries with ADRD, and CMS evaluating innovations in care models, including hospice care in ADRD, our intention was to conduct a cohort study of MA beneficiaries with an ICU stay to compare discharge status and mortality by whether or not individuals had diagnostic ADRD before their ICU stay. We hypothesized that patients with ADRD would be less likely to be discharged home and would have an increased risk of short-term and/or long-term mortality. We are not aware of any published study that examined ICU outcomes among MA enrollees living with ADRD.
Am J Crit Care. 2023;32(4):249-255. © 2023 American Association of Critical-Care Nurses
