Diabetes Quality of Care
among Nursing Home New
Admission Cohort
Charlene C. Quinn, RN, PhD
Assistant Professor
University of Maryland School of Medicine
Division of Gerontology
Funded by National Institute on Aging
(RO1 AG08221; R29 AG11407)
Presentation Objective:
Describe diabetes care and
utilization in nursing home cohort
• Significance/Study Rationale
• Methods
• Results
– Secondary prevention procedures use
– Identify adverse outcomes
– Findings by dementia status
• Relevance to practice and policy
Significance
• Diabetes affects 20% of all older adults,
higher rates for minorities
• Expenditures attributable to diabetes
estimated at $132 billion
• Nursing home care (15.1%) one of
major expenditure groups
• Eliminating or reducing problems
caused by diabetes could improve
quality of life and reduce expenditures
Study Rationale
• Diabetes is common in the long-term
care setting
• Strong evidence for comprehensive
monitoring reduces or slows diabetes
complications
• Management of diabetes may be
complicated by dementia status
Study Questions
• What are the characteristics of diabetic
nursing home residents?
• What secondary prevention procedures
are diabetics receiving prior to and
during the nursing home stay?
• What diabetic complications are
occurring pre- and post-admission to a
nursing home?
• Is there a dementia effect?
Method
• “Epidemiology of Dementia in Nursing
Homes”
– Cohort study of 2285 new admissions
to 59 nursing homes (NH) in Maryland
– Patients assessed at admission (19921995), expert panel determined
dementia status
– Residents followed 2 years after
admission
• Medical chart, MDS
Method
• Linked Medicare and Medicaid claims
data to subjects in parent study
• Diabetes identified by admission MDS,
n=404 (17.7% of sample)
• Medicare records indicating any
secondary prevention procedures by
CPT codes
Method
• Medicare records for patient
complications for inpatient and
outpatient encounters in five categories
determined by ICD-9 codes:
– Diabetes
– Dehydration
– Macro- and micro-vascular events
– Metabolic complications
– Infection complications
Selected Sample Characteristics
(N=404)
Characteristics
Mean age
Dementia
(n=185)
79.9
No dementia
(n=219)
78.2
*
Males
29.7%
27.9%
White
67.0%
82.1% ***
NH length of stay
423.9 days
241.3 days***
No dementia vs. dementia: ***p<.001, **p<.01, *p<.05
Selected Sample Characteristics
(N=404)
Characteristics
HCC (cost estimate 12mo.
Dementia No dementia
(n=185)
(n=219)
$15,240
$19,596 ***
pre-admit)
Medicaid
34.6%
24.2%
*
Medicare Qualified Stay
54.3%
69.7%
**
No dementia vs. dementia: ***p<.001, **p<.01, *p<.05
Secondary Prevention Procedures,
Period 6 months prior to NH admission
Procedure
Dementia (%) No dementia (%)
HbA1c
12.4
21.0 *
Fasting plasma
glucose
Eye exam
53.0
64.8 *
8.1
21.5 ***
Lipid profile
11.9
14.6
Serum creatinine
43.8
58.0 **
Urinalysis
20.5
30.6 *
n=404, unadjusted
No dementia vs. dementia: ***p<.001, **p<.01, *p<.05
Secondary Prevention Procedures,
Period NH admission through 6 months
Procedure
Dementia (%) No dementia(%)
HbA1c
11.4
14.6
Fasting plasma
glucose
84.3
84.0
Eye exam
Lipid profile
Serum creatinine
7.0
21.6
80.0
8.2
25.6
80.4
Urinalysis
50.3
53.4
N=404, unadjusted
No dementia vs. dementia: ***p<.001, **p<.01, *p<.05
Secondary Prevention Procedures,
NH placement (all diabetics)
Procedure
Pre-admit Post-admit
(%)
(%)
17.1
13.1
HbA1c
Fasting plasma glucose
59.4
84.2 ***
Eye exam
Lipid profile
Serum creatinine
15.3
13.4
51.5
7.7
23.8 ***
80.2 ***
Urinalysis
26.0
52.0 ***
N=404, unadjusted
Time effect: ***p<.001, **p<.01, *p<.05
Hospitalizations for Patient
Complications
6 months Pre-admit
6 months Post-admit
Dementia
%
No Dementia
%
Dehydration
16.2
17.4
11.9
Micro/macro
events
4.9
9.1
5.9
9.6 *
Metabolic
3.8
3.7
2.7
0.9
Infections
19.5
39.5
19.6
51.6 *
11.9
17.3
Complication
Diabetes
Overall hosp.
N=404, unadjusted
Dementia No Dementia
%
%
8.7
15.1
27.9 *
No dementia vs. dementia: *p<.05 Time trend *p<.05
Summary
• Rate of diabetes in new admissions to
statewide sample of 59 NHs is 18%.
• Person with diabetes and dementia
– Older age
– More likely non-white
– Have longer NH lengths of stay
– Incur lower Medicare costs before nursing
home admission (HCC)
– Less likely to be a Medicare qualified stay
– More likely Medicaid eligible at admission
Summary
• In the 6-month period prior to NH admission,
diabetics with dementia are less likely to
receive secondary prevention procedures.
• In the first 6 months of NH admission, all
diabetics, regardless of dementia status, are
more likely to receive secondary prevention
procedures, except for HbA1c and eye exams.
– For diabetics with dementia, it appears the
NH admission is providing a “process” for
diabetics to receive diabetes management
Summary
• Hospitalizations resulting from 5 major
groups of complications are similar between
dementia and non-dementia groups
– Higher rates of overall hospitalization
post-NH admission for those without
dementia reflects higher pre-NH admission
rates of hospitalization
– Micro- and macro-vascular
hospitalizations increase slightly post-NH
admission (time p=.042, adjusting for
demographics, comorbidities, NH LOS)
Relevance to Practice and Policy
• Nursing homes are caring for a large number
of older persons with diabetes and are
providing secondary prevention procedures to
prevent or delay diabetes complications
– Increased importance among current NH
environment with much shorter NH LOS (27
days)
– Identify with patients and families important
secondary procedures (eye exams, HbA1c)
– Increasing prevalence of diabetes will
increase number of persons admitted to
NHs with diabetes and comorbidities
Relevance to Practice and Policy
• Intensive treatment for all diabetics in
the long-term care setting may not be
appropriate
• Managing diabetes for potential
complications may impact Medicare
utilization and costs
Co-Investigators
Jay Magaziner
Bruce Stuart
Ann Gruber-Baldini
Conrad May
Lynda Burton
Ilene Zuckerman
Van Doren Hsu
Sheryl Zimmerman
Kenneth Boockvar
J. Richard Hebel
Verita Custis Buie
Ajith Silva
Steve Kittner