Among Community Elders - NCBI

10 downloads 1870 Views 423KB Size Report
As a cost reductionmethod, the Health Care Financing. Administration (HCFA) has proposed that the Medicare program contract with certain health maintenance ...
PUBLIC HEALTH BRIEFS

A Prospective Study of Functional Status Among Community Elders LAURENCE G. BRANCH, PuD, SIDNEY KATZ, MD, KATHLEEN KNIEPMANN, MPH, AND JOSEPH A. PAPSIDERO, PHD Abstract: A six-year prospective study provides estimates of functional status (independent, dependent, nursing home resident, or deceased) according to age, gender, and previous functional status for Caucasian elders initially living in the community. Half the cohort had sustained independence for the six years; of those dependent at the beginning, one-fourth to one-third regained independent function within 15 months, and one-fifth regained selfsufficiency within five years. (Am J Public Health 1984; 74:266268.)

Introduction Eleven per cent of the United States population aged 65 years or more (25.5 million individuals in 1980) presently accounts for approximately 25-30 per cent of the nation's health care expenditures." 2 As a cost reduction method, the Health Care Financing Administration (HCFA) has proposed that the Medicare program contract with certain health maintenance organizations (HMOs) to provide health care to enrolled elders for a fixed cost,3 based on the adjusted average per capita cost (AAPCC) expected for each Medicare enrollee in a specific geographic area, refined by age and sex, and by institutional and welfare status. Subgroup cost factors vary from .60 to 2.60 of the AAPCC. We have developed population-based functional status data that may help HMO management to define the limits of the service program offered for the fixed price received, and may act as an additional refinement of the AAPCC itself.

Methods A Massachusetts statewide stratified area probability sample of noninstitionalized people aged 65 years or older was drawn in late 1974 (year 0); personal interviews were conducted with 1,625 elderly respondents (79 per cent response rate). Personal interviews were conducted in 1976 (year 1.25) with 1,317 of the original respondents (103 had died during the interim; 26 had entered the long-term care (LTC) institutional system; 179 were lost to follow-up). Personal interviews were collected from 825 members of the original cohort in 1980 (year 6) (303 respondents had Address reprint requests to Laurence G. Branch, PhD, Department of Social Medicine and Health Policy, Division on Aging, Harvard Medical School, 643 Huntington Avenue, Boston, MA 02115. Dr. Branch is also affiliated with the Department of Maternal and Child Health and Aging, Harvard School of Public Health, and the Boston VA Outpatient Clinic Geriatric Research, Education, and Clinical Center. Dr. Katz is with the Division of Biology and Medicine, Brown University, Providence, RI; Ms. Kniepmann is with the Department of Social Medicine and Health Policy, Division on Aging, Harvard Medical School; Dr. Papsidero is with the Department of Community Health Sciences, Michigan State University. This paper, submitted to the Journal March 8, 1983, was revised and accepted for publication June 3, 1983. © 1984 American Journal of Public Health 0090-0036/84 $1.50

266

died; 60 had entered LTC institutions; 146 were lost to follow-up). * Functional status in these analyses is measured by the person's reported independence or dependence in basic activities of daily living (ADL). Only four of the ADL proposed by Katz4'5 were assessed: bathing, dressing, transferring, eating.** Two other areas, used previously by Branch,6-8 were also assessed: personal grooming (shaving, brushing hair, trimming toenails) and walking across a small room. Adding these two ADL areas into a summary index increases the percentage of community elders who are dependent in one or more areas; 7.6 per cent of the elders were dependent (defined as using the assistance of another person) by the Katz 4-item ADL index at year 0, while 15.9 per cent were dependent by the Branch 6-item index. Results are expressed in relation to both indices. The wording of the items in the questionnaires used to develop the summary ADL scores was the same for the three interviews. Because there were too few non-Caucasians to analyze separately (n = 41), self-reported data for Caucasian elders only are presented.

Results Approximately half of the elders remain independent in ADL throughout the six years of this longitudinal investigation. Table 1 presents the sex and age proportions of initially independent elders according to four outcomes 15 months later. Both age and sex significantly influenced short-term functional status.*** Those independent at the outset and aged 85 years or more had approximately three times the probability of being dependent or dead by the end of the interval, and approximately seven to nine times the likelihood of being in a nursing home. Table 2 indicates that, for those dependent at the beginning of the interval, sustained dependence is the most likely outcome, although approximately one-fourth to onethird regained independent function by the end of the 15month interval. Those aged 85 years or more were least likely to change from dependent to independent. Approximately one-fifth of the community-living elders who entered the 15-month interval dependent in ADL were dead by the end of the interval. Table 3 presents the proportions of elders with a 15month history of sustained independence according to the *The 20 per cent lost to follow-up after year 0 were not statistically different from those interviewed at year 6 with respect to age, sex, living situation, and functional status as determined at year 0.

**Loss of function generally occurs in an ordered fashion; the omitted areas, toileting and continence, are typically the third and fifth areas of progressive dysfunction.45 The exclusion of these two areas should not preclude comparison with complete Katz ADL scales. ***Tables with age-specific sex rates are available from the first author as are an array of 26 possible functional status profiles over the six years distributed by the four- and six-item ADL.

AJPH March 1984, Vol. 74, No. 3

PUBLIC HEALTH BRIEFS TABLE 1-15-Month Changes In Status among Functionally Independent Elders in the Community (Massachusetts, 1974-1976)

(n)

Sustained Independence

Loss of Independence in Community

Entered Nursing Home

Died

(1295)a (1182)

.880 .876

.044 .063

.017 .012

.059 .050

Sex Female

(784)

Male

(699) (511)

.889 .886 .867 .861

.051 .072 .033 .050

.020 .013 .012 .010

.040 .030 .088 .079

.926 .912 .846 .840 .554 .582

.023 .040 .066 .095 .162 .182

.006 .003 .020 .014 .122 .109

.045 .044 .068 .052

Total

(483)

Age (years) 65-74 75-84 85+

(823) (775) (395)

(349) (74) (55)

Chi-Squared

Significance

4-item: .001

616-item: tm

0

01

j4ie:.0

4-item:.001

6ie:.0

1162

6-item:.001

.127

aProbabilities based on Katz 4-item ADL presented top; Branch 6-item ADL bottom.

TABLE 2-15-Month Changes in Status among Functionally Dependent Elders in the Community (Massachusetts, 1974-1976)

Total

Sex Female

(n)

Sustained Dependence in Community

Entered

Returned to Independence

Home

Died

(117)a (230)

.239 .335

.521 .435

.026 .048

.214 .183

(72)

.264 .350 .200

.028 .057 .022 .027

.153 1134

.301

.556 .459 .467 .383

.308 .440 .262 .330 .043 .095

.462 .390 .500 .420 .696 .571

.0 .020 .048 .057 .043 .095

.231 .150 .190 .193 1217 .238

(157)

Male

Age (years) 65-74 75-84 85+

(45) (73) (52) (100) (42) (88) (23) (42)

Chi-Squared Significance

Nursing

4ie:N

4-item: NS

.311 1288

J

6ie:N

6-item: NS

4-item: NS 6itm 0

6-item:.01

aProbabilities based on Katz 4-item ADL presented top; Branch 6-item ADL bottom.

TABLE 3-Changes in Status between Year 1.25 and Year 6 among Elders In the Community with a 15-Month History of Sustained Independence (Massachusetts, 1974-1980)

Total

Sex Female Male

(n)

Continued Sustained Independence

Loss of Independence in Community

Entered Nursing Home

Died

(1013)a (917)

.699 .653

.044 .100

.041 .038

.215 .208

(613) (542) (400) (375)

.731 .675

.049 .120

.050 .044

.650

.038

.621

.072

.028 .029

.170 .160 285 .277

.772 .731 .589 .524 .289 .172

.031 .079 .072 .135 .053 .241

.024 .023

Chi-Squared Significance

l

j

4

4-item:.001

6-item:..001

6ie:.0

Age (years) 65-74

75-84 85+

(670)

(620) (304) (267) (38) (29)

.066 .064 .158 .138

.173 .168 .273 .277 .500 .448

-tm:.0 4-item .001

|

6ie:.0 6-item:.001

aProbabilities based on Katz 4-item ADL presented top; Branch 6-item ADL bottom.

AJPH March 1984, Vol. 74, No. 3

267

PUBLIC HEALTH BRIEFS TABLE 4-Changes In Status between Year 1.25 and Year 6 among Elders In the Community with a 15-Month History of Some Functional Dependence (Massachusetts, 1974-1980)

Total

(n)

Returned to Independence

Sustained Dependence

(137)a (233)

.182 .223

.190 .262

(94)

.170

Entered Nursing Home

Died

.095 .086

.533 .429

Chi-Squared Significance

Sex Female

.202

.085

.543

.200 .297 .29.163 .279 .176

.091

.412 .512 .471

(56) (106) (54)

.357 .330 .093

.054 .047 .093

(91) (27)

.176

(165)

Male

(43)

(68) Age (years) 65-74

75-84 85+

(36)

.0 .028

.179 .292 .185 .264 .222 .167

.116 .074

.087 .185 .194

.411 .330 .630 .473 .593 .611

4ie:N

4-item: NS

( J

6-item: NS

|4-item- .0001

(6-item: 001 6ie:.0

aProbabilities based on Katz 4-item ADL presented top; Branch 6-item ADL bottom.

four functional status outcomes over a nearly five-year subsequent interval. Approximately one-fifth of these elders were dead by the end of the interval, 4 per cent were in nursing homes, 4-10 per cent were dependent in ADL but living int the community. Approximately two-thirds of these elders sistained independence at the end of the five-year interval, however. Table 4 indicates the functional status outcomes after five years: for elders with a history of some functional dependence. Only age was associated significantly with outcomes over the long term. The majority of these elders were dead within five years and almost one in ten were in nursing homes. Discussion One implication of this project is the demonstrated feasibility of mtnitoring the functional status of total communities 'in a longitudinal study design, as alternatives to mortality and morbidity rates. These preliminary Massachusetts data may also be useful to HMOs and to HCFA when entering into specific risk contracts for the provision of health care services to elders for a fixed cost based on an AAPCC formula. While 5-6 per cent of ADL-independent elders are expected to enter the high-cost pre-death cohort (Table 1) compared to .18-21 per cent of ADL-dependent elders, a new cohort of elderly HMO enrollees might not include the same proportions of initially independent and dependent individuals, so that adjustments would have to be made in estimates related to AAPCC capitation rates. The data presented emphasize that the choice of operational ADL measures is important. There was a greater than two-fold difference in the rate of loss of independence during the five-year interval among those with a history of sustained independence depending on the measure (.044 dependent by

268

the 4-item ADL versus .100 dependent by the 6-item ADL as indicated in Table 3). The 4-item index capitalizes on the stability of the functional assessment; the 6-item index is more sensitive to changes in functional status. Lastly, these findings invite additional analyses. Just as traditional life-expectancy tables provide estimates of additional longevity expected for individuals of a specific age and sex, a companion analysis provides estimates of "active life expectancy" of those initially independent for specific age and sex subgroups.9 REFERENCES 1. US Bureau of the Census: Statistical abstract of the United States: 1981. Washington, DC: GPO, 1981. 2. Gibson RM: National health expenditures, 1979. Health Care Financing Review 1980; summer: 1-36. 3. Kunkel SA, Powell CK: The adjusted average per capita cost under risk contracts with providers of health care. Transaction for the Society of Actuaries 1981; 33:221-230. 4. Katz S, Hedrick SC, Henderson NS: The measurement of long-term care needs and impact. Health Med Care Serv Rev 1979; 2:1-21. 5. Katz S, Akpom CA: A measure of primary socio-biological functions. Int J Health Serv 1976; 6:493-508. 6. Branch LG, Jette AM: A prospective study of long-term care institutionalization among the elderly. Am J Public Health 1982; 72:1373-1379. 7. Branch LG: Vulnerable Elders. Gerontological Society Monograph No. 6. Washington, DC: Gerontologic Society, 1980. 8. Jette AM, Branch LG: Framingham disability study: II. physical disability among the aging. Am J Public Health 1981; 71:1211-1216. 9. Katz S, Branch LG, Branson MH, Papsidero JA, Beck JC, Greer DS: Active life expectancy. N Engi J Med, 1983; 309:1218-1224.

ACKNOWLEDGMENTS This research was supported in part by a grant from the National Center for Health Services Research, DHHS, and from previous grants from the US Administration on Aging and from the Massachusetts Department of Public Health. The authors gratefully acknowledge the thoughtful comments of Paul Densen, Ellen Jones, and Alan Jette on an earlier version of this paper.

AJPH March 1984, Vol. 74, No. 3