HOS HighlightsHOS Highlights - CMS...• Enrollees with IHD and CHF are more likely not to have...
Transcript of HOS HighlightsHOS Highlights - CMS...• Enrollees with IHD and CHF are more likely not to have...
HOS HighlightsHOS Highlights Coexisting Illness and Heart Disease Among Elderly
Medicare Managed Care Enrollees Arlene S. Bierman, M.D., M.S.
INTRODUCTION
High rates of comorbidity present a challenge in providing care to elderly Medicare managed care enrollees. Comorbidity or the presence of coexisting illness strongly influences utilization, costs, and outcomes of health care. Ischemic heart disease (IHD) and congestive heart failure (CHF) are leading causes of morbidity and mortality among Medicare beneficiaries. Both have been the targets of successful quality improvement initiatives by CMS (Jencks, Huff, and Cuerdon, 2003). Medicare HEDIS® has targeted improved management of hypertension and diabetes, as well as smoking cessation, all important risk factors for IHD and CHF. The impact of disease management programs on outcomes for these conditions is being evaluated in CMS demonstration projects (Haffer et al., 2003). Additional improvements in quality and outcomes of care for beneficiaries with these conditions may be achieved by improving management of common coexisting illnesses.
The large sample size of the Medicare Health Outcomes Survey (HOS) affords an unprecedented opportunity to look at the prevalence and patterns of coexisting illness among enrollees with IHD and CHF. The author is with Faculities of Medicine and Nursing, University of Toronto, and Inner City Health Research Unit, St. Michael’s Hospital, Toronto, Canada. The views expressed in this article are those of the author and do not necessarily reflect those of the University of Toronto, St. Michael’s Hospital, or the Centers for Medicare & Medicaid Services (CMS).
The HOS instrument contains items for assessing physical and mental health status, chronic conditions, clinical symptoms, and demographic information (National Committee for Quality Assurance, 2000). The following figures are based on the responses of 167,854 community-dwelling individuals age 65 or over enrolled in Medicare managed care who participated in the HOS Cohort I Baseline Survey. The sample is 58 percent female and includes 31,315 respondents who report having IHD, and 11,239 respondents who report having CHF.
Enrollees with IHD or CHF have lower incomes and lower levels of educational attainment than the overall M+C enrollee population, placing them at increased risk of encountering both financial and nonfinancial barriers to care. They also report higher levels of comorbidity, and a higher prevalence of common chronic conditions. Nine out of ten enrollees with these conditions report having three or more chronic conditions, and they report having a mean of five chronic conditions. In addition to hypertension and diabetes, risk factors for heart disease, there is a high prevalence of chronic non-fatal disabling conditions that can affect outcomes and compliance with treatments including arthritis, severe low-back pain, urinary incontinence, and sensory impairments. The high prevalence of depressed mood underscores the need to also address mental health issues in these
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beneficiaries. In addition, the burden of coexisting illness varies by sex, race/ethnicity, and socioeconomic status. Females, African-American, Latino, and socioeconomically disadvantaged enrollees report a higher burden of coexisting illness.
Future efforts should focus on implementing and evaluating models of care for beneficiaries with heart disease that address the coexisting illnesses present in these patients. Opportunities also exist for prevention. Insights from the HOS survey can inform the development of comprehensive models of care.
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Figure 1
Differences in Income and Education Among Elderly Medicare+Choice (M+C) Enrollees with IHD or CHF Compared to All M+C Enrollees: 1998
50 All
Male 44 Female 42
39 39 40
35
32 32 30 31 30
30 26
cP
eren
t
22 20
20 17 15
13
9 10 9
0
All IHD CHF All IHD CHF
Annual Household Income Less Than Less Than 12 Years of Education
$10,000
NOTE: IHD is ischemic heart disease; CHF is congestive heart failure.
SOURCE: Centers for Medicare & Medicaid Services: 1998 Medicare Health Outcome Survey, Cohort Ι Baseline Measurement Data Set.
• Females are much more likely than males to report annual household incomes less than $10,000. Twenty percent of all females compared to nine percent of males are in this income category.
• Enrollees with CHF are more likely to report annual household incomes less than $10,000 then the overall M+C enrollee population. Nearly one in three females with CHF are in this income category.
• Enrollees with IHD and CHF are more likely not to have completed high school than the overall M+C enrollee population. Thirty-five percent of enrollees with IHD, and 42 percent with CHF have not completed high school.
• Females with IHD and CHF are more likely not to have completed high school than males reporting these conditions.
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Figure 2
Differences in the Percent of Elderly Medicare+Choice (M+C) with IHD and CHF Who Report Three or More Chronic Conditions Compared to All M+C Enrollees: 1998
100 All 92 92 9390 Male 90 86
Female 82
80
70
Per
cen
t
60
47 48 50 45
40
30
20
10
0
All IHD CHF
NOTE: IHD is ischemic heart disease; CHF is congestive heart failure.
SOURCE: Centers for Medicare & Medicaid Services: 1998 Medicare Health Outcome Survey, Cohort Ι Baseline Measurement Data Set.
• Comorbidity among Medicare managed care enrollees is common, with 47 percent of respondents reporting three or more chronic conditions.
• Enrollees with IHD and CHF are much more likely to report having three or more chronic conditions than the overall M+C enrollee population.
• Eighty-six percent of enrollees with IHD, and 92 percent of enrollees with CHF report having three or more chronic conditions.
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Fig
ure
3
Dif
fere
nce
s in
th
e P
erce
nt
of
Eld
erly
Med
icar
e+C
ho
ice
En
rolle
es w
ith
IHD
an
d C
HF
Rep
ort
ing
Dia
bet
es, S
tro
ke, o
r C
OP
D/A
sth
ma
Co
mp
ared
to
All
M+C
En
rolle
es:
1998
Percent
40
Mal
e34
35
Fem
ale
31
30
26
25
25
25
2522
20
20
19
18
17
17
16
14
15
13
12
9 10
7
5 0
All
IHD
C
HF
A
ll IH
D
CH
F
All
IHD
C
HF
Dia
bete
s S
trok
e A
sthm
a/C
OP
D
NO
TE
: IH
D is
isch
emic
hea
rt d
isea
se; C
HF
is c
onge
stiv
e he
art f
ailu
re; a
nd C
OP
D is
chr
onic
obs
truc
tive
pulm
onar
y di
seas
e.
SO
UR
CE
: Cen
ters
for
Med
icar
e &
Med
icai
d S
ervi
ces:
199
8 M
edic
are
Hea
lth O
utco
me
Sur
vey,
Coh
ort Ι
Bas
elin
e M
easu
rem
ent D
ata
Set
.
•
Dia
bete
s, a
ris
k fa
ctor
s fo
r IH
D a
nd C
HF,
is m
uch
mor
e pr
eval
ent a
mon
g en
rolle
es r
epor
ting
thes
e co
nditi
ons.
•
One
-qua
rter
of m
ales
and
one
-thir
d of
fem
ales
rep
ortin
g IH
D o
r C
HF
also
rep
ort a
his
tory
of d
iabe
tes.
•
In a
dditi
on,
abou
t tw
o-th
irds
of
mal
es a
nd t
hree
-qua
rter
s of
fem
ales
rep
ortin
g IH
D o
r C
HF
also
rep
ort
a hi
stor
y of
hy
pert
ensi
on, a
noth
er r
isk
fact
or fo
r th
ese
cond
ition
s (d
ata
not s
how
n).
•
Str
oke
and
CO
PD/a
sthm
a ar
e m
ore
prev
alen
t am
ong
enro
llees
with
IH
D o
r C
HF
than
in
the
over
all
M+C
enr
olle
e po
pula
tions
.
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Figure 4
Differences in the Percent of Elderly Medicare+Choice (M+C) with IHD and CHF Reporting Low Back Pain Compared to All M+C Enrollees: 1998
Per
cen
t 30 All
Male 26 Female
25
22 22
20 18 17
15 13
12 11
9 10
5
0
All IHD CHF
NOTE: IHD is ischemic heart disease; CHF is congestive heart failure.
SOURCE: Centers for Medicare & Medicaid Services: 1998 Medicare Health Outcome Survey, Cohort Ι Baseline Measurement Data Set.
• Arthritis and severe low back pain may place a barrier to complying with recommenda-tions to exercise and are commonly reported by all M+C enrollees. However, they are more often reported by enrollees with CHF and IHD, and more prevalent in females.
• Roughly one-half of males and two-thirds of females reporting IHD or CHF also report having arthritis (data not shown).
• One in five enrollees with CHF report having low back pain that interferes with their activities all or most of the time.
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Figure 5
Differences in the Percent of Elderly Medicare+Choice (M+C) Enrollees with IHD and CHF Reporting Depressed Mood Compared to All M+C Enrollees: 1998
Per
cen
t 30 All 28
Male 26 Female 24 24 25
19 20
16 15 15 13
10 10
5
0
All IHD CHF
NOTE: IHD is ischemic heart disease; CHF is congestive heart failure.
SOURCE: Centers for Medicare & Medicaid Services: 1998 Medicare Health Outcome Survey, Cohort Ι Baseline Measurement Data Set.
• Depressed mood is prevalent in Medicare managed care enrollees. One of every eight enrollees responded yes when asked if…In the past year, have you felt depressed or sad much of the time?
• Enrollees reporting IHD and CHF are much more likely to report having a depressed mood than the overall M+C enrollee population. Nineteen percent of enrollees with IHD and 26 percent of enrollees with CHF report depressed mood.
• Females are more likely than males to report having a depressed mood.
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Figure 6
Differences in the Percent of Elderly Medicare+Choice (M+C) Enrollees with IHD and CHF Reporting Urinary Incontinence Compared to All M+C Enrollees: 1998
Per
cen
t 45 All
41Male
40 38 Female 37
35 32 32
30 28 27
25 25
22
20
15
10
5
0
All IHD CHF
NOTE: IHD is ischemic heart disease; CHF is congestive heart failure.
SOURCE: Centers for Medicare & Medicaid Services: 1998 Medicare Health Outcome Survey, Cohort Ι Baseline Measurement Data Set.
• Urinary incontinence, can place a barrier to both compliance with diuretic therapy and recommendations to exercise, is commonly reported by all M+C enrollees. Urinary incontinence is more often reported by enrollees with CHF and IHD, and more prevalent in females.
• Twenty-seven percent of males with IHD and 32 percent of males with CHF report urinary incontinence.
• Thirty-eight percent of females with IHD and 41 percent of females with CHF report urinary incontinence.
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Figure 7
Differences in the Percent of Elderly Medicare+Choice (M+C) Enrollees with IHD and CHF Reporting Sensory Impairment Compared to All M+C Enrollees: 1998
25 Male
Female
Per
cen
t
20
15
10
5
0
All IHD CHF All IHD CHF
Hearing Impairment Visual Impairment
NOTE: IHD is ischemic heart disease; CHF is congestive heart failure.
SOURCE: Centers for Medicare & Medicaid Services: 1998 Medicare Health Outcome Survey, Cohort Ι Baseline Measurement Data Set.
• Difficulty hearing or hearing impairment, and difficulty seeing or visual impairment are more prevalent among enrollees with IHD and CHF and report these conditions more than the overall M+C enrollee population.
• Hearing impairment is more prevalent in males than females, and visual impairment is more prevalent in females than males.
• One in five males with CHF also report hearing impairment, and one in seven females with CHF also report visual impairment.
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Figure 8
Differences in Physical Functioning as Measured by the SF-36® PCS Among Elderly Medicare+Choice (M+C) Enrollees with IHD and CHF Reporting Compared to All M+C Enrollees: 1998
SF
-36®
PC
S
46 All
44 Male 44 43 Female
42 42
40 40
38 38
36 36
35
34 34
32 32
30
All IHD CHF
NOTE: IHD is ischemic heart disease; CHF is congestive heart failure; and PCS is physical component summary.
SOURCE: Centers for Medicare & Medicaid Services: 1998 Medicare Health Outcome Survey, Cohort Ι Baseline Measurement Data Set.
• Enrollees reporting IHD have lower scores on the SF-36® PCS score or worse function-al status than the overall M+C enrollee population.
• Enrollees with CHF have lower scores on the SF-36® PCS score than individuals report-ing IHD.
• Females with IHD and CHF have lower scores on the SF-36® PCS score than the males. • Females reporting CHF have a mean SF-36® PCS score of 32, one standard deviation below that of the overall M+C enrollee population.
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Differences in
45
40
35
30
Figure 9
Percent of Enrollees Age 65 Reporting Both CHF and Diabetes by Race/Ethnicity, Income, and Education: 1998
43 Diabetes
39
35 34 32
ent 25
cP
er 20
15
10
5
0
All Non-Hispanic Black Hispanic or Less Than A Poor Less or African American Spanish High School Than $10,000
Education Income NOTE: CHF is congestive heart failure.
SOURCE: Centers for Medicare & Medicaid Services: 1998 Medicare Health Outcome Survey, Cohort Ι Baseline Measurement Data Set.
• Diabetes is a common comorbidity among enrollees reporting CHF. There are variations in the prevalence of diabetes by race/ethnicity and socioeconomic status.
• Forty-three percent of non-hispanic black or African-American enrollees and 39 percent of Hispanic enrollees reporting CHF also report having diabetes.
• Thirty-five percent of enrollees with annual household incomes below $10,000 reporting CHF also report having diabetes.
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Figure 10
Differences in Mean Number of Chronic Conditions Among Enrollees Age 65 Reporting CHF, by Race/Ethnicity, Income, and Education: 1998
Mea
n
5.6
5.48 5.5 5.44
5.4 5.31
5.29 5.3
5.2
5.1 5.01
5
4.9
4.8
4.7
All Non-Hispanic Black Hispanic or Less Than A Poor Less or African American Spanish High School Than $10,000
Education Income NOTE: CHF is congestive heart failure.
SOURCE: Centers for Medicare & Medicaid Services: 1998 Medicare Health Outcome Survey, Cohort Ι Baseline Measurement Data Set.
• Enrollees reporting CHF report a mean of five comorbid conditions. There are variations in the mean number of comorbid conditions by race/ethnicity and socioeconomic status.
• Non-hispanic black or African-American enrollees and Hispanics enrollees reporting CHF report more coexisting illness.
• Enrollees with annual household incomes less than $10,000 and those who have not completed high school also report more coexisting illnesses.
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ACKNOWLEDGMENTS
The author would like to thank Samuel J. Sinclair, and Barbara Gandek for their contributions to the data analysis and Samuel C. Haffer for his suggestions on the manuscript.
REFERENCES
Haffer, S., Bowen, S., Shannon, E., et al.: Assessing Beneficiary Health Outcomes and Disease Management Initiatives in Medicare. Disease Management and Health Outcomes 11(2):111-124, February 2003. Jencks, S., Huff, E., and Cuerdon, D.: Change in the Quality of Care Delivered to Medicare Beneficiaries, 1998-1999 to 2000-2001. Journal of American Medical Association 289(3):305-312, January 2003. National Committee for Quality Assurance: HEDIS®2000: Specifications for the Medicare Health Outcomes Survey. National Committee for Quality Assurance. Washington, DC. 2000.
Reprint Requests: Arlene S. Bierman, M.D., M.S., University of Toronto, Inner City Health Research Unit, St. Michael’s Hospital, 30 Bond Street (70 Richmond Street East, 4th Floor) Toronto, Ontario, Canada M5B 1W8. E-mail: [email protected]
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