Obesity, Healthcare Utilization, and Outcomes Among Post-Acute - PowerPoint PPT Presentation

Obesity, Healthcare Utilization, and Outcomes Among Post-Acute Skilled Nursing Facility Residents with Hip Fracture Cyrus M. Kosar, MA, Kali S. Thomas, PhD, Pedro Gozalo, PhD and Vincent Mor, PhD Center for Gerontology and Healthcare Research Brown University Supported by the National Institute on Aging (P01 AG-027296, PI: Mor)

Background (1)  ~1/3 rd of adults aged 65 years and greater have been estimated to be obese  Obesity predisposes older adults to multiple comorbidities and complicates chronic illnesses  Prevalent among 18-25% of new nursing facility admissions (Lapane, 2002 & 2005)  Rising obesity rates in nursing facilities: ° Moderate to severe obesity [body mass index (BMI) ≥35] in select facilities increased from 15% in 2000 to 24% in 2010 (Felix, 2015)

Background (2)  Nursing facility residents with obesity may differentially experience adverse outcomes  Facilities with higher populations of residents with obesity may face disadvantages ° Physical burden on staff ° Financial burden on facility (under-reimbursement)

Objectives  Identify differences in resource utilization among nursing facility residents by level of obesity  Determine whether level of obesity confers excess risk for adverse outcomes among nursing facility residents with hip fracture

Data Sources  Minimum Data Set (MDS) assessments  The Medicare Provider and Analysis Review (MedPAR) Files

Study Cohorts  Cohort #1: ° All residents “present” during April 1, 2014 ° N=1,272,002  Cohort #2: ° SNF admissions directly from hospital (2011-2014), age 65+ with a diagnosis of hip fracture ° Exclude patients with history of SNF utilization ° Excluded underweight residents (BMI <18.5) ° N = 330,097 residents

Outcomes  Level of assistance required in completing Activities of Daily Living (ADLs)  Readmission to acute care within 30 days  Planned discharge to home within 30 days  Staying in the nursing facility for 100 or more days (long- stay status) 7

Analysis  Robust Poisson regression used to estimate the risk for outcomes associated with mild, moderate and severe obesity relative to normal weight ° Adjusted for • Age • Gender • Comorbidity burden (Charlson index) • Cognitive function (cognitive function scale [CFS] score) • Facility fixed effects 8

Facility-Level Prevalence of Obesity, April 2014 Moderate to Severe Obesity Any Obesity .08 .05 .04 .06 .03 .04 .02 .02 .01 0 0 0 10 20 30 40 0 20 40 60 9

Prevalence of Obesity among Nursing Home Residents (30,36] (25,30] (15,25] [5,15] 10

Prevalence of Moderate to Severe Obesity among Nursing Home Residents (15,20] (10,15] (5,10] [0,5] 11

Resource Utilization by Obesity Level (1) Obesity Class I Class II Class III Normal/ Overweight BMI 30 to <35 BMI 35 to <40 BMI >=40 ADL n= 428635 n=124175 n=64503 n=63923 Bed Mobility - n (%) None 62554 (15) 19195 (15) 9476 (15) 8310 (13) Setup help only 36260 (8) 10410 (8) 5056 (8) 4394 (7) One person Physical Assist 211299 (49) 54505 (44) 26502 (41) 23660 (37) Two person Physical Assist 118401 (28) 40005 (32) 23415 (36) 27508 (43) Did not occur 90 (0) 52 (0) 48 (0) 45 (0) Transfer - n (%) None 54634 (13) 17160 (14) 8493 (13) 7394 (12) Setup help only 36124 (8) 10544 (8) 5174 (8) 4621 (7) One person Physical Assist 208139 (49) 52481 (42) 25294 (39) 21904 (34) Two person Physical Assist 126435 (29) 43039 (35) 24927 (39) 28843 (45) Did not occur 3279 (1) 946 (1) 613 (1) 1156 (2) 12

Resource Utilization by Obesity Level (2) Obesity Class I Class II Class III Normal/ Overweight BMI 30 to <35 BMI 35 to <40 BMI >=40 ADL n= 428635 n=124175 n=64503 n=63923 Dressing - n (%) None 30740 (7) 9517 (8) 4733 (7) 4014 (6) Setup help only 31991 (7) 9378 (8) 4499 (7) 3785 (6) One person Physical Assist 334418 (78) 93399 (75) 47913 (74) 46246 (72) Two person Physical Assist 31123 (7) 11804 (10) 7308 (11) 9791 (15) Did not occur 265 (0) 58 (0) 38 (0) 69 (0) Toilet - n (%) None 45093 (11) 14033 (11) 6893 (11) 5702 (9) Setup help only 30828 (7) 9232 (7) 4380 (7) 3735 (6) One person Physical Assist 258793 (60) 67883 (55) 33675 (52) 31358 (49) Two person Physical Assist 93489 (22) 32901 (26) 19456 (30) 23026 (36) Did not occur 405 (0) 119 (0) 95 (0) 98 (0) 13

Characteristics of Post-Acute Hip Fracture Residents by Obesity Level Non-obese Obese Class I Class II Class III BMI 30.0 – 34.9 BMI 35.0 – 39.9 BMI≥40 BMI<30 Characteristic n= 279609 n=35803 n=10325 n=4360 Age in years - mean (sd) 84.7 (7.5) 81.6 (7.5) 79.2 (7.5) 76.3 (7.4) Female sex - % 74 74 77 81 Non-White Race - % 11 10 11 12 ADL Score - mean (sd) 18.6 (3.3) 18.4 (3.2) 18.4 (3.2) 18.6 (3.1) Charlson Score - mean (sd) 1.9 (1.7) 2.1 (1.8) 2.2 (1.8) 2.3 (1.9) CFS Score - % Cognitively Intact 52 65 72 76 Mild Impairment 22 20 17 16 Moderate Impairment 20 12 9 6 Severe Impairment 4 2 1 1 Dementia Dx - % 28 17 12 8 14

Association of Obesity and Outcomes, Post-Acute Hip Fracture Residents Outcome n/N (%) RR (95% CI) Readmitted within 30 days Non-obese, BMI<30 34818/279609 (12.5) Referent Obesity Class I, BMI 30.0 – 34.9 4691/35803 (13.1) 1.10 (1.05 1.14) Obesity Class II, BMI 35.0 – 39.9 1482/10325 (14.4) 1.28 (1.20 1.37) Obesity Class III, BMI≥40 737/4360 (16.9) 1.47 (1.33 1.62) Discharge to home within 30 days RR (95% CI) Non-obese, BMI<30 96335/241041 (40.0) Referent Obesity Class I, BMI 30.0 – 34.9 12804/31288 (40.9) 0.92 (0.90 0.93) Obesity Class II, BMI 35.0 – 39.9 3547/9006 (39.3) 0.82 (0.80 0.84) Obesity Class III, BMI≥40 1356/3699 (36.6) 0.71 (0.68 0.75) Became Long-Stay Resident RR (95% CI) Non-obese, BMI<30 83283/279609 (29.8) Referent Obesity Class I, BMI 30.0 – 34.9 9609/35803 (26.8) 1.04 (1.01 1.06) Obesity Class II, BMI 35.0 – 39.9 2858/10325 (27.7) 1.17 (1.13 1.21) Obesity Class III, BMI≥40 1317/4360 (30.2) 1.36 (1.28 1.43) 15

Discussion (1)  The rate of using two staff members for assistance with ADLs among nursing facility residents with moderate and severe obesity is substantially higher  Post-acute nursing facility residents admitted with hip fracture are: ° More likely to have a 30-day readmission ° Less likely to be discharged back to the community within 30 days ° More likely to fulfill long-stay resident criteria

Discussion (2)  Important implications for: ° Clinical care ° Risk sharing initiatives/payment models • Comprehensive Care for Joint Replacement (CJR) ° Risk adjusted quality and outcome measurement ° Reimbursement (RUGs)

Study Limitations  Inaccuracy of BMI in capturing obesity ° Declines in the presence of shorter stature  Non-generalizability of risk estimates to residents repeatedly utilizing post-acute care and those in custodial care  Cohort study findings subject to residual confounding ° Large, heterogeneous normal weight group 18

Future Research Areas  Does having a higher share of nursing facilty residents with obesity negatively impact facilities’ residents without obesity or all residents generally? ° How do facilities compensate for resources used without reimbursement?  The impact of obesity on functional recovery  Resident obesity and injuries among nursing facility staff

Thank you! cyrus_kosar@brown.edu