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THE URBAN INSTITUTE. Examining Long-Term Care Episodes and Care History for Medicare Beneficiaries: A Longitudinal Analysis of Elderly Individuals with Congestive Heart Failure Stephanie Maxwell & Timothy Waidmann APHA Annual Meeting Boston, MA November 6, 2006. Background

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Examining Long-Term Care Episodes and

Care History for Medicare Beneficiaries:

A Longitudinal Analysis of Elderly Individuals with

Congestive Heart Failure

Stephanie Maxwell & Timothy Waidmann

APHA Annual Meeting

Boston, MA

November 6, 2006

  • Congestive heart failure (CHF) is the leading medical condition among the elderly.   
  • Significant policy concern regarding CHF hospitalization rates
  • CHF is a common target of disease management programs. 
  • Few large-scale studies have explored the CHF patients’ use of long-term care (LTC) services and Medicare services combined

Overview of Study Design

  • Longitudinal (36-month) analyses
  • National cohort of elderly who were first hospitalized for CHF in 1999. 
  • Identify patterns over three years of Medicare service use and spending, enrollment in Medicaid, and nursing home entry. 
  • Estimate hazard models of risks of re-hospitalization, nursing home admission and death, controlling for health status. 
data sources mainly 1999 2002 files

Data Sources(mainly 1999-2002 files)

100% Medicare claims files (all service types)

100% Medicare enrollment files

100% MDS patient assessment records

Area Resource File and Interstudy HMO Files


Defining the Cohort in the Claims Data

  • Final cohort = 296,462 elderly
  • Cohort consists of elderly hospitalized, in 1999, for their first hospitalization for CHF.
  • The principal diagnosis field of acute hospital records was searched for a set of diagnosis codes indicating CHF as the primary reason for hospitalization.
  • Scanned a 5-year “look-back” period of hospital claims (1994-1998 claims) to screen out individuals whose first CHF admission occurred before 1999.
  • To assure a comparable “look-back period”, we included only those age-eligible for Medicare in January 1994 in the cohort.
statistical methods

Statistical Methods

Bivariate analyses -- of outcomes stratified by patient and area characteristics

Survival models -- to estimate the effects of covariates on the instantaneous risk of an outcome, through measuring the elapsed time before an outcome is observed.

Two-part use and spending models – estimated models for the first six months following CHF hospitalization and also for the three years following CHF hospitalization.

outcomes measures of hazard models

Outcomes Measures of Hazard Models


Subsequent CHF hospitalization

Subsequent non-CHF hospitalization

Medicaid enrollment

Nursing home entry

outcomes measures of two part use and spending models

Outcomes Measures of Two-Part Use and Spending Models

CHF hospitalizations

Other hospitalizations

SNF stays

Home health use

Hospital outpatient use

Physician services use

person level independent variables

Person-Level Independent Variables

Demographics (age group, race, sex)

Charlson comorbidity score

Length of stay of the index CHF hospitalization

Nursing home use prior to index CHF hospitalization

Utilization and spending variables between the index CHF hospitalization and outcome:

Quarterly physician spending

Quarterly hospital outpatient spending

Quarterly acute hospital spending (except in models of death and non-CHF hospitalizations)

CHF hospitalizations (except when used as an outcome)

Oher hospitalizations (except when use as an outcome)

SNF stays

Medicare home health use

Nursing home use (except when used as an outcome)

county level independent variables
Urban influence

HMO penetration

Median county income

Supply rates per 1000 elderly:

All physicians


Short-term hospital beds

Long-term hospital beds

SNF beds

Nursing home beds

Presence of a facility in the county:

Short-term hospital

Nursing home

Rural health clinic

Federally qualified health clinic

Population mortality rates for 10 selected medical conditions

County-Level Independent Variables
summary of findings
Summary of Findings

Over 3 years following index hospitalization for CHF:

  • 36% had additional CHF hospitalizations
  • 68% had hospitalizations for other conditions
  • 42% had SNF stays
  • 15% entered a nursing home (non-Medicare)
  • 7% enrolled in Medicaid
  • 56% died
  • 11% had NH use prior to their index CHF hospitalization
  • Average 3-year spending = $35,000
    • Non-CHF hospitalizations was largest source of spending
findings death
Findings – Death

SNF use is the dominant risk

  • Age -- 5 additional years  13% to 30% higher risk
  • Charlson -- additional comorbidity  10% higher risk
  • Index LOS -- additional day  2% higher risk
  • SNF use  200% higher risk
  • Physician spending per quarter ($thousands)  15 to 40% higher risk
  • NF use  15% to 47% higher risk
findings chf hospitalizations
Findings – CHF Hospitalizations

Approximately 15% increased risk associated with:

  • 5-year age increase
  • Additional comorbidity
  • Race: Black
  • Physician spending per quarter ($thousands)
  • Home health use

Whites have higher death risks and blacks have higher rehospitalization risks. This is consistent with each other in suggesting that whites are more severely ill once hospitalized.

findings other hospitalizations
Findings – Other Hospitalizations

Compared to CHF hospitalization, key differences

are regarding race and home health use

  • Blacks  10% to 20% higher risk for CHF hospitalizations
  • But blacks  5% to 10% lower risk for other hospitalizations
  • Home health use  15% higher risk for CHF hospitalizations
  • But home health use  20% lower risk for other hospitalizations
findings nursing home entry
Findings – Nursing Home Entry

SNF use and prior NH use are dominant risks

  • SNF use  several hundred percent higher risk
  • Prior NH use  100% higher risk
  • Additional CHF hospitalizations  20% higher risk
  • Other hospitalizations  5% to 20% higher risk
findings medicaid enrollment
Findings – Medicaid Enrollment

SNF use and NH use are the dominant risks

(200% to 300% higher risk)

Three factors each increasing risk by ~ 6% to 24%:

  • Prior NH use
  • Hospitalizations
  • Home health use

Race: black  40% to 100% higher risk

methodological contributions to the chf literature
Methodological Contributions to the CHF Literature
  • Large-scale, national study of CHF population with a long follow-up (36 months).
  • Survival analysis jointly accounts for utilization and mortality risk. This is important when studying elderly or high-mortality conditions. Logistic regression may give misleading impressions.
  • Controlled for health status using comorbidity index and prior nursing home use.
  • Controlled for area variation using state and 6-level urban influence variable. In terms of urban influence, risks hinged on large metro county residence. An urban/rural flag would incorrectly attribute practice patterns typical in large center cities to the surrounding metro areas and to smaller cities.
  • Higher CHF rehospitalization among African Americans. Target for disease management programs?
  • Bivariate findings suggest decreasing intensity of care with age. Multivariate models do not.
  • Importance of more than CHF hospitalization in cohort.
  • Geographic variation in utilization and health.
main study limitation missing data on social support income functional status
Main Study Limitation: Missing Data on Social Support, Income, Functional Status
  • This study had mixed findings regarding the effect (sign) of home health use on outcomes. Our findings on home health use in relation to SNF use may point to influential characteristics not available in our data: social support, individual income, and ADL information on community residents.
  • The importance of these factors in understanding LTC use is well-established in the literature.
  • This study’s findings suggest that these factors may be important in understanding medical use as well, when examining a chronic and ultimately debilitating disease like CHF.


Principal Investigators:

Stephanie Maxwell, PhD and Timothy Waidmann, PhD

202-261-5825 202-261-5718

Health Policy Center

The Urban Institute

2100 M Street, NW

Washington, DC 20037

fax: 202-223-1149


Centers for Medicare and Medicaid Services