It’s time to get engaged in decision-making and policy conversations about the care of older adults, urges a new report from the Dartmouth Atlas Project of the Dartmouth Atlas of Health Care, which has documented variations in the use and distribution of medical resources in America for more than 20 years.
The population is aging, and statistics show that adults age 65 and older spend a lot of time in contact with the health care system.
“We have to be very cognizant of the care needs, not just the medical needs but the care needs, for this population,” says Terry Fulmer of The John A. Hartford Foundation, the report’s sponsor.
‘The Patient Experience’
The Dartmouth Atlas Project report, Our Parents, Ourselves: Health Care for an Aging Population, released Wednesday, Feb. 17, deviates from previous reports by focusing on the patient experience, rather than the cost and quality of health care. Researchers used Medicare billing data from 2012, broken down into 306 hospital referral regions (HRR). Represented on a map of the United States, the data allow us to see variations in care in the context of geography.
Older adults are in a health care setting 17 days a year, on average, but Manhattan residents might spend almost 25 days in clinics, labs and hospitals.
Where we live does make a difference in our health care experience, the data show. Residents of popular retirement destinations such as Florida and Arizona see a greater number of clinicians and specialists than Minnesotans do, for example. Not surprisingly, they also spend many more days going to doctor appointments.
Older adults in western states are less likely to live in a nursing home than those in the middle of the country, it turns out, but there is also a lower concentration of residents age 75 and older than in, say, the Dakotas.
“A major lesson to take away is the great diversity of populations and approaches to care across the country,” the report authors write. “The ability to identify others who may be ahead of the curve on any particular metric can be leveraged by a learning health care system.”
The report highlights older adults’ interactions with the health care community, including total contact days (outpatient appointments, hospital stays, procedures, tests and imaging), inpatient days and how many times these people saw each clinician or specialist providing care.
Nationally, older adults are in a health care setting 17 days a year, on average. Residents of Long Island and Manhattan, however, might spend almost 25 days in clinics, labs and hospitals. Patients with multiple conditions or dementia may see contact days double.
“It’s often a joke that all elderly people want to talk about is their health care, that health care is a kind of substitute for a social life,” says the report’s lead author, Dr. Julie Bynum. “That may be a joke, but I think these numbers should give us pause — pause to ask whether, as an older adult or one of their family members, we want to be spending our time this way, shuttling back and forth between visits? Would it be possible to organize care such that we can reclaim some of those days to take care of ourselves?”
Bynum points to another finding — that for 40 percent of older adults, a specialist is the predominant provider of care, meaning that he or she is the clinician a patient sees most often.
“It’s unclear whether the specialists see themselves as providing coordinating service typically associated with primary care or whether patients think of them as a primary care doctor,” Bynum notes, but the need to coordinate care grows as the need for more providers grows — when a patient has several conditions, for example. And better outpatient management may help prevent hospital admissions and readmissions, duplication of services and conflicting instructions, according to the report.
What Needs Changing
The report identifies other areas needing improvement: reducing cancer screenings late in life and improving end-of-life care.
For many older adults, screening for early breast and prostate cancers after age 75 is unnecessary, yet 24 percent of women and roughly 20 percent of men 75 and older had screenings in 2012. Rates were highest in eastern and southeastern regions.
Bynum expresses concern at the continued screenings. “They’re much more likely to die of something else before the cancer would ever make them sick, in which case we don’t want to put them through treatment that really can’t benefit them,” she says.
Regarding end-of-life care, the report found that practices and decisions at this difficult time don’t always match patients’ wishes or provide the most beneficial care. For example, despite many patients’ preference for comfort and less-intensive care at the end of their lives, patients averaged almost four days in the ICU in the last six months of life, with some patients spending more than a week. In addition, hospice referrals often came too late to be beneficial to patients and family caregivers.
Despite problems with the current function of the health care system, “there’s actually a good alignment between what older adults really need and want in health care and what health reform is trying to achieve,” Bynum says. “That alignment is based on older adults being a diverse group of people who need care that is highly coordinated, avoids putting people in institutional settings like hospitals and nursing homes, avoids harm of care and helps people achieve their individual goals, whether that’s for better quality of life or life extension.”
Fulmer also expresses optimism that the report can inform discussions that bring about change.
“We have an impending crisis in care given the paucity of care providers and now family caregivers,” Fulmer says, “and now we need to extend the opportunities they have to build on the information in this report so that they can be advising their loved ones in the best way possible.”