Variations in risk-adjusted outcomes in a managed acute/long-term care program for frail elderly individuals

Abstract

Objective. To develop and investigate the properties of three performance measures based on risk-adjusted health outcomes for a frail, elderly, community-dwelling population enrolled in a managed, acute, and long-term care program. Design. Retrospective analyses of an administrative dataset containing individual level records with information about socioeconomics, health, functional and cognitive status, diagnoses, and treatments. We estimated risk-adjustment models predicting mortality, decline in functional status, and decline in self-assessed health. Each model includes individual risk factors and indicator variables for the program site in which the individual enrolled. Sites were ranked based on their performance in each risk-adjusted outcome, and the properties of these performance measures were investigated. Setting. Twenty-eight sites of the Program of All-Inclusive Care for the Elderly (PACE) that provide primary, acute, and long-term care services under capitated Medicare and Medicaid payment to a nursing home certifiable, and functionally and cognitively frail community-dwelling elderly population. Study participants. Three thousand one hundred and thirty-eight individuals who were newly enrolled between 1 January 1998 and 31 December 1999. The average age of these enrollees was 78 years, 27% were male, 50% were diagnosed with dementia, and they had approximately 4 Activities of Daily Living limitations and 7.4 Instrumental Activities of Daily Living limitations. Main outcome measures. Risk-adjustment models, performance ranking for each site, and correlations between performance rankings. Results. We present risk-adjustment models for mortality, change in functional status, and self-assessed health status. We found substantial variation across sites in performance, but no correlation between performance with respect to different outcomes. Conclusions. The variations in outcomes suggest that sites can improve their performance by learning from the practices of those with the best outcomes. Further research is required to identify processes of care that lead to best outcomes. © International Society for Quality in Health Care and Oxford University Press 2004; all rights reserved.