Continuity of Care and Healthcare Utilization in Older Adults with Dementia in Fee-for-Service Medicare

Abstract

Importance

Poor continuity of care may contribute to high healthcare spending and adverse patient outcomes in dementia.

Objective

To examine the association between medical provider continuity and healthcare utilization, testing, and spending in older adults with dementia.

Design

Observational retrospective cohort from 2012 using inverse probability weighted analysis.

Setting

National sample in fee-for-service Medicare.

Participants

1,416,369 continuously enrolled, community dwelling, fee-for-service Medicare beneficiaries age ≥ 65 with a claims-based dementia diagnosis and at least 4 ambulatory visits in 2012.

Exposure

Continuity of care score measured on patient visits across physicians over 12 months. A higher continuity score is assigned to visit patterns in which a larger share of the patient’s total visits are with fewer providers. Score range from 0 to 1 was examined in low, medium, and high continuity tertiles.

Main Outcomes and Measures

Outcomes include all-cause hospitalization, ambulatory care sensitive condition hospitalization, emergency department visit, imaging and lab testing (CT head, chest x-ray, urinalysis, and urine culture), and healthcare spending (overall, hospital and skilled nursing facility, and physician).

Results

Beneficiaries with dementia who had lower levels of continuity of care were younger, higher income, and had more comorbid medical conditions. Almost 50% of patients had at least one hospitalization and emergency department visit during the year. Utilization was lower with increasing level of continuity. Specifically comparing the highest versus lowest continuity groups, annual rates per beneficiary of hospitalization (0.83 vs 0.88), emergency department visits (0.84 vs 0.99), CT head (0.71 vs 0.83), urinalysis (0.72 vs 1.09), and healthcare spending (total spending $22,004 vs $24,371) were higher with lower continuity even after accounting for sociodemographic factors and comorbidity burden (all p values < 0.001). The rate of ambulatory care sensitive condition hospitalization was similar across continuity groups.

Conclusions and Relevance

Among older fee-for-service Medicare beneficiaries with a dementia diagnosis, lower continuity of care is associated with higher rates of hospitalization, emergency department visits, testing, and healthcare spending. Further research into these relationships, including potentially relevant clinical, provider, and systems factors, can inform whether improving continuity of care in this population may benefit patients and the wider health system.