More than dollars: Healthcare utilization among spouses of persons with dementia

IF 4.3 2区 医学 Q1 GERIATRICS & GERONTOLOGY
Molly J. Horstman MD, MS
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In the United States, families provide most of the long-term care to persons with dementia.<span><sup>1</sup></span> Family members need to maintain sufficient health to fulfill caregiving roles and responsibilities to sustain this system. Spouses of a person with dementia may have less time and fewer financial resources to participate in recommended health behaviors and receive healthcare services, which, over time, may impact their ability to care for the person with dementia.<span><sup>5</sup></span></p><p>In this issue, <i>Ingraham</i> et al. present the results of a matched study examining Medicare Fee-for-Service expenditures for spouses of persons living with dementia compared with spouses of persons without dementia in the 5 years after the person with dementia was diagnosed with dementia.<span><sup>6</sup></span> Using the Health and Retirement Study with linked Medicare Claims, the authors measured three categories of health utilization costs: (1) inpatient or hospital expenditures; (2) outpatient or ambulatory expenditures, which included emergency room visits if a hospitalization did not follow the visit; and (3) skilled nursing facility, hospice, and home health expenditures. In the adjusted analysis, there was no difference in total Medicare expenditures between spouses of persons with dementia and spouses of persons without dementia in the 5 years after dementia was diagnosed. However, in Year 5, there was an increase in total Medicare expenditures among spouses of persons living with dementia driven by an increase in inpatient expenditures, with a total difference of $2748 (95% CI $321–$5447).</p><p>The results of this study differ from prior matched studies examining healthcare expenditures among spouses of persons living with dementia.<span><sup>3, 4, 7, 8</sup></span> As the authors note, prior studies had relied on claims data to identify persons with dementia, while the methods used by <i>Ingraham</i> et al. for identifying incident diagnoses of dementia from the Health and Retirement Study identified adults at an earlier stage of the disease. However, several other differences existed between this study and prior published studies. These include the methods by which spouses were identified, the type of insurance the spouse had, and the types of expenditures included in the total expenditures.<span><sup>3, 4, 7, 8</sup></span> In addition, <i>Ingraham</i> et al. matched the spouses based on whether their partner needed help with activities of daily living and instrumental activities of daily living, which was not done in prior studies. Regardless, the study from <i>Ingraham</i> et al. adds to our overall understanding that healthcare expenditures for spouses of persons with dementia are at least the same as healthcare expenditures for spouses of persons without dementia and maybe greater for some types of healthcare expenditures.</p><p>With the broad categories of healthcare expenditures, it is impossible to know what the expenditures represent. In a study of older adults with multiple chronic medical conditions, one would expect there to be healthcare expenditures in both groups. However, similar healthcare expenditures between the two groups do not mean that the groups are receiving equivalent care. In the United States, where overuse, underuse, and misuse of health care are common, the broad categories of healthcare expenditures do not provide insights into the quality or value of the care received.<span><sup>9</sup></span> In a study published 20 years ago, spouses of persons living with dementia had a higher number of emergency room visits compared with spouses of persons without dementia.<span><sup>4</sup></span> Whether this is still the case is not addressed in the current study, but it does raise the question of whether there are meaningful differences in the care received that are not reflected in the total expenditures. Understanding differences in the care received between the two groups may provide insights into opportunities for interventions to improve the health of spouses of persons with dementia.</p><p>The increased inpatient expenditures for spouses in the fifth year following diagnosis are concerning. This is consistent with prior literature on caregivers of persons with dementia who are more likely to have an overnight hospitalization when the care recipient has more advanced impairments and when the caregiver has been providing care for a longer duration.<span><sup>10, 11</sup></span> Hospital admissions are not benign. The functional and cognitive decline commonly seen in hospitalized older adults may impact the spouse's ability to fulfill caregiving responsibilities.<span><sup>12, 13</sup></span> Persons with dementia are at increased risk for mortality, and in this study, 41% of persons with dementia died within the 5-year follow-up.<span><sup>6</sup></span> Yet, that still leaves over half of the spousal dyads alive at the end of 5 years. For these couples, hospitalization of the spouse may create a domino effect where hospitalization of the spouse leads to unanticipated or unwanted changes for the person with dementia (Figure 1).</p><p>Focusing on only the care received by the spouse is an incomplete story. Just as caring for a person with dementia impacts the health of the spouse, hospitalization of the spouse likely impacts the person with dementia. Prior research has shown that hospitalization of an older adult can increase the risk of death in their spouse in the subsequent year.<span><sup>14</sup></span> Hospitalization of a family member for a serious physical illness also increases the mean per person medical charges in the subsequent 3 years for the family.<span><sup>15</sup></span> Although the literature specific to spouses of persons with dementia is limited, one study showed that persons with dementia are at increased risk for admission to the hospital if their spouse had been admitted to the hospital in the prior 180 days.<span><sup>16</sup></span> Thus, it is likely that the expenditures seen in the spouse can impact healthcare expenditures and outcomes for the person with dementia. Examining healthcare expenditures for spouses in isolation may underestimate the actual cost of healthcare utilization.</p><p>The research literature on what happens after a spouse of a person with dementia is hospitalized is almost nonexistent. However, any clinician who cares for older adults has many anecdotes, and it is not a stretch to think of a plausible scenario for what could happen (Figure 1). Hospitalization of the spouse may result in acute declines in the spouse's function, cognition, and health. This may result in a mismatch between the person with dementia's care needs and the capacity of the spouse to provide the care needed, triggering hospitalization for the person with dementia. Less capable of meeting the person with dementia's care needs, the spouse may be forced to move the person with dementia to a nursing home before they had intended. Moving the person with dementia to a nursing home may trigger or worsen depression and anxiety in the spouse, resulting in further declines in their health.<span><sup>17</sup></span> The initial hospitalization is not just a healthcare expenditure. It is the beginning of a story of what happens to two people whose health and well-being are connected.</p><p>Regardless of the total amount of healthcare expenditures of spouses of persons with dementia, these adults are receiving health care. They are coming to our clinics, visiting our emergency rooms, being admitted to our hospitals, and staying at our skilled nursing facilities. In the absence of more effective disease-modifying treatments, the need to support spouses and other family caregivers of persons with dementia will remain an urgent need. To truly understand what health systems can do, more nuanced information is needed about the types of care spouses are receiving and the impact of this care on spouses and persons with dementia.</p><p>MH created the concept for the editorial, wrote the editorial, and prepared the editorial for publication.</p><p>None.</p><p>None.</p><p>This work is supported in part by the Office of Research and Development, Houston Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety (IQuESt) grant (CIN 13–413) at the Michael E. DeBakey VA Medical Center, Houston, TX. Dr. Horstman is supported by Career Development Award Number 1IK2HX003163-01A2 from the United States Department of Veterans Affairs Health Services Research and Development Service of the VA Office of Research and Development.</p>","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":null,"pages":null},"PeriodicalIF":4.3000,"publicationDate":"2024-08-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.19174","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Journal of the American Geriatrics Society","FirstCategoryId":"3","ListUrlMain":"https://onlinelibrary.wiley.com/doi/10.1111/jgs.19174","RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"GERIATRICS & GERONTOLOGY","Score":null,"Total":0}
引用次数: 0

Abstract

Being the spouse of a person with dementia can be a significant source of strain and can negatively impact one's health.1 Although not all spouses serve as the primary caregiver, many spouses provide physical or emotional support to the person with dementia. Studies have shown that spouses of persons with dementia are more likely to have depression, anxiety, and sleep disturbances compared with spouses of persons who do not have dementia.2-4 Identifying opportunities to improve health among spouses of persons with dementia is essential. In the United States, families provide most of the long-term care to persons with dementia.1 Family members need to maintain sufficient health to fulfill caregiving roles and responsibilities to sustain this system. Spouses of a person with dementia may have less time and fewer financial resources to participate in recommended health behaviors and receive healthcare services, which, over time, may impact their ability to care for the person with dementia.5

In this issue, Ingraham et al. present the results of a matched study examining Medicare Fee-for-Service expenditures for spouses of persons living with dementia compared with spouses of persons without dementia in the 5 years after the person with dementia was diagnosed with dementia.6 Using the Health and Retirement Study with linked Medicare Claims, the authors measured three categories of health utilization costs: (1) inpatient or hospital expenditures; (2) outpatient or ambulatory expenditures, which included emergency room visits if a hospitalization did not follow the visit; and (3) skilled nursing facility, hospice, and home health expenditures. In the adjusted analysis, there was no difference in total Medicare expenditures between spouses of persons with dementia and spouses of persons without dementia in the 5 years after dementia was diagnosed. However, in Year 5, there was an increase in total Medicare expenditures among spouses of persons living with dementia driven by an increase in inpatient expenditures, with a total difference of $2748 (95% CI $321–$5447).

The results of this study differ from prior matched studies examining healthcare expenditures among spouses of persons living with dementia.3, 4, 7, 8 As the authors note, prior studies had relied on claims data to identify persons with dementia, while the methods used by Ingraham et al. for identifying incident diagnoses of dementia from the Health and Retirement Study identified adults at an earlier stage of the disease. However, several other differences existed between this study and prior published studies. These include the methods by which spouses were identified, the type of insurance the spouse had, and the types of expenditures included in the total expenditures.3, 4, 7, 8 In addition, Ingraham et al. matched the spouses based on whether their partner needed help with activities of daily living and instrumental activities of daily living, which was not done in prior studies. Regardless, the study from Ingraham et al. adds to our overall understanding that healthcare expenditures for spouses of persons with dementia are at least the same as healthcare expenditures for spouses of persons without dementia and maybe greater for some types of healthcare expenditures.

With the broad categories of healthcare expenditures, it is impossible to know what the expenditures represent. In a study of older adults with multiple chronic medical conditions, one would expect there to be healthcare expenditures in both groups. However, similar healthcare expenditures between the two groups do not mean that the groups are receiving equivalent care. In the United States, where overuse, underuse, and misuse of health care are common, the broad categories of healthcare expenditures do not provide insights into the quality or value of the care received.9 In a study published 20 years ago, spouses of persons living with dementia had a higher number of emergency room visits compared with spouses of persons without dementia.4 Whether this is still the case is not addressed in the current study, but it does raise the question of whether there are meaningful differences in the care received that are not reflected in the total expenditures. Understanding differences in the care received between the two groups may provide insights into opportunities for interventions to improve the health of spouses of persons with dementia.

The increased inpatient expenditures for spouses in the fifth year following diagnosis are concerning. This is consistent with prior literature on caregivers of persons with dementia who are more likely to have an overnight hospitalization when the care recipient has more advanced impairments and when the caregiver has been providing care for a longer duration.10, 11 Hospital admissions are not benign. The functional and cognitive decline commonly seen in hospitalized older adults may impact the spouse's ability to fulfill caregiving responsibilities.12, 13 Persons with dementia are at increased risk for mortality, and in this study, 41% of persons with dementia died within the 5-year follow-up.6 Yet, that still leaves over half of the spousal dyads alive at the end of 5 years. For these couples, hospitalization of the spouse may create a domino effect where hospitalization of the spouse leads to unanticipated or unwanted changes for the person with dementia (Figure 1).

Focusing on only the care received by the spouse is an incomplete story. Just as caring for a person with dementia impacts the health of the spouse, hospitalization of the spouse likely impacts the person with dementia. Prior research has shown that hospitalization of an older adult can increase the risk of death in their spouse in the subsequent year.14 Hospitalization of a family member for a serious physical illness also increases the mean per person medical charges in the subsequent 3 years for the family.15 Although the literature specific to spouses of persons with dementia is limited, one study showed that persons with dementia are at increased risk for admission to the hospital if their spouse had been admitted to the hospital in the prior 180 days.16 Thus, it is likely that the expenditures seen in the spouse can impact healthcare expenditures and outcomes for the person with dementia. Examining healthcare expenditures for spouses in isolation may underestimate the actual cost of healthcare utilization.

The research literature on what happens after a spouse of a person with dementia is hospitalized is almost nonexistent. However, any clinician who cares for older adults has many anecdotes, and it is not a stretch to think of a plausible scenario for what could happen (Figure 1). Hospitalization of the spouse may result in acute declines in the spouse's function, cognition, and health. This may result in a mismatch between the person with dementia's care needs and the capacity of the spouse to provide the care needed, triggering hospitalization for the person with dementia. Less capable of meeting the person with dementia's care needs, the spouse may be forced to move the person with dementia to a nursing home before they had intended. Moving the person with dementia to a nursing home may trigger or worsen depression and anxiety in the spouse, resulting in further declines in their health.17 The initial hospitalization is not just a healthcare expenditure. It is the beginning of a story of what happens to two people whose health and well-being are connected.

Regardless of the total amount of healthcare expenditures of spouses of persons with dementia, these adults are receiving health care. They are coming to our clinics, visiting our emergency rooms, being admitted to our hospitals, and staying at our skilled nursing facilities. In the absence of more effective disease-modifying treatments, the need to support spouses and other family caregivers of persons with dementia will remain an urgent need. To truly understand what health systems can do, more nuanced information is needed about the types of care spouses are receiving and the impact of this care on spouses and persons with dementia.

MH created the concept for the editorial, wrote the editorial, and prepared the editorial for publication.

None.

None.

This work is supported in part by the Office of Research and Development, Houston Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety (IQuESt) grant (CIN 13–413) at the Michael E. DeBakey VA Medical Center, Houston, TX. Dr. Horstman is supported by Career Development Award Number 1IK2HX003163-01A2 from the United States Department of Veterans Affairs Health Services Research and Development Service of the VA Office of Research and Development.

Abstract Image

不仅仅是金钱:痴呆症患者配偶的医疗保健使用情况。
作为痴呆症患者的配偶可能会承受巨大的压力,并对患者的健康产生负面影响。1 尽管并非所有的配偶都是主要的照顾者,但许多配偶都会为痴呆症患者提供身体或情感上的支持。研究表明,与非痴呆症患者的配偶相比,痴呆症患者的配偶更容易患抑郁症、焦虑症和睡眠障碍。在美国,大部分痴呆症患者的长期护理都是由家庭提供的。1 家庭成员需要保持足够的健康,以履行护理角色和责任,从而维持这一系统。痴呆症患者的配偶参与建议的健康行为和接受医疗保健服务的时间和财力可能较少,随着时间的推移,这可能会影响他们照顾痴呆症患者的能力。5 在本期杂志中,Ingraham 等人介绍了一项配对研究的结果,该研究对痴呆症患者的配偶与非痴呆症患者的配偶在痴呆症患者被诊断出患有痴呆症后 5 年内的医疗保险付费服务支出进行了比较。作者利用健康与退休研究(Health and Retirement Study)和关联的医疗保险索赔(Medicare Claims),测算了三类医疗利用成本:(1)住院病人或医院支出;(2)门诊病人或非住院病人支出,其中包括急诊就诊(如果就诊后没有住院);以及(3)专业护理机构、临终关怀和家庭医疗支出。在调整后的分析中,痴呆症患者的配偶与非痴呆症患者的配偶在痴呆症确诊后 5 年内的医疗保险总支出没有差异。然而,在第 5 年,痴呆症患者配偶的医疗保险总支出因住院费用的增加而增加,总差额为 2748 美元(95% CI 为 321 美元至 5447 美元)、4、7、8 正如作者所指出的,之前的研究依赖于索赔数据来识别痴呆症患者,而 Ingraham 等人从健康与退休研究(Health and Retirement Study)中使用的识别痴呆症事件诊断的方法则识别了处于疾病早期阶段的成年人。不过,这项研究与之前发表的研究还存在其他一些差异。3, 4, 7, 8 此外,Ingraham 等人还根据配偶是否需要帮助进行日常生活活动和工具性日常生活活动对配偶进行了匹配,而之前的研究并没有这样做。无论如何,Ingraham 等人的研究让我们进一步了解到,痴呆症患者配偶的医疗保健支出至少与非痴呆症患者配偶的医疗保健支出相同,某些类型的医疗保健支出可能更高。在一项针对患有多种慢性疾病的老年人的研究中,我们预计两组人都会有医疗保健支出。然而,两组之间相似的医疗支出并不意味着这两组接受了同等的医疗服务。9 在 20 年前发表的一项研究中,痴呆症患者的配偶与非痴呆症患者的配偶相比,去急诊室就诊的次数更多。4 目前的研究并未涉及这种情况是否仍然存在,但这确实提出了一个问题,即在所接受的医疗服务中是否存在未反映在总支出中的有意义的差异。了解两组患者在接受护理方面的差异可能会为干预措施提供启示,从而改善痴呆症患者配偶的健康状况。这与之前有关痴呆症患者照护者的文献一致,当照护者的损伤程度更严重、照护时间更长时,他们更有可能住院过夜。住院老年人常见的功能和认知能力下降可能会影响配偶履行护理责任的能力。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
CiteScore
10.00
自引率
6.30%
发文量
504
审稿时长
3-6 weeks
期刊介绍: Journal of the American Geriatrics Society (JAGS) is the go-to journal for clinical aging research. We provide a diverse, interprofessional community of healthcare professionals with the latest insights on geriatrics education, clinical practice, and public policy—all supporting the high-quality, person-centered care essential to our well-being as we age. Since the publication of our first edition in 1953, JAGS has remained one of the oldest and most impactful journals dedicated exclusively to gerontology and geriatrics.
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