Volume 5, Issue 3 , Pages 139-145, September 2011
Quantitative Evaluation of Age Disparities in the Quality of Geriatric Acute Medical Care in Japan
Article Outline
- Summary
- 1. Introduction
- 2. Materials and methods
- 3. Results
- 4. Discussion
- Acknowledgments
- References
- Copyright
Summary
Background
In the era of an aging population, stakeholders should recognize the presence of age disparities for the delivery of acute care. Few studies have assessed the association between resource use as an input and functional recovery as a health outcome among older people. We examined the disparity in care quality for patients aged
≥60 years with stroke, hip arthropathy or bone injury.
Methods
Using a Japanese administrative database with 5 years of data starting in 2004, we identified 35,566 patients with stroke, 2537 with hip arthropathy, and 7427 with hip bone injury across 151 acute care hospitals. Demographic characteristics, functional status at admission and discharge, length of stay (LOS), and total charges (TC) were analyzed for specific age categories (60–69, 70–79 and≥80 years). Independent effects of age on these parameters were determined.
Results
Overall, 10,239 (29%) patients with stroke, 321 (13%) with arthropathy, and 747 (36%) with bone injury were aged≥80 years old. The proportions of surgical procedures for patients aged≥70 years with stroke, arthropathy and bone injury were 20%, 91% and 90%, respectively. The 70–79-year-old group was associated with greater LOS or TC for each disease, except for LOS in arthropathy. The degree of functional recovery decreased with increasing age, except hip arthropathy.
Conclusion
Disparities in resource use and functional recovery were observed by disease and age. To maintain social activity among older people, stakeholders should acknowledge the variations in care quality and establish priorities for quality improvement initiatives in hip arthropathy.
Keywords: aged, age disparity, functional recovery, quality of health care
1. Introduction
Aging of the population is a worldwide demographic trend that has become particularly noticeable in the 21st century. The life expectancy (LE) in Japan was 67.8 years in 1960 and increased to 82.4 years in 2006. LE has also increased in the other Group of Seven (G7) countries and was approximately 80 years in 20061. Japanese stakeholders need to determine the sustainability of the healthcare system because approximately 20% of the Japanese population is at least 65 years old and, in 2006, accounted for over US$137 billion in healthcare expenditure, nearly 4.5% of the gross national product2. Suzuki reported that, as the proportion of people aged ≥65 years will double to 39.6% by 2050, compared with 21.5% in 2007, Japan will probably be the first country to face an extremely aged generation1, 3.
Several researchers have attempted to estimate the impact of aging on healthcare expenditure associated with acute and long-term care4, 5. Some macroeconomic reassessments of aging have shown that aging has a relatively small effect on the increase in healthcare expenditure, but changes in practice behavior could not be ignored5. Technological innovations should encourage providers to change their practice behavior. Some innovations are less invasive, but more costly, and are expected to be applied in older patients6, 7. Multidisciplinary care systems have been evaluated and introduced into healthcare delivery, including acute care medicine, with targeting based on age differences8, 9, 10, 11, 12, 13.
Surgical innovations and care systems have undergone microeconomic evaluation for the quality of medical care delivered to older patients, but the findings have not always been derived from comprehensive assessments of the quality of medical care. Some were limited to individual diseases such as stroke or hip fracture, and others did not include surgical procedures in older patients9, 11. Comprehensive and comparative assessments covering relevant clinical variables would allow stakeholders to determine priorities for healthcare provision, particularly in geriatric medicine.
Using a Japanese national administrative database containing clinical information, as well as the quantity and time of medical care, this study focused on patients aged >60 years who were admitted for treatment of stroke, hip arthropathy or bone injury in acute care hospitals14. We aimed to provide descriptive statistics for three specific diseases and to examine the age disparities in the use of surgical procedures using multivariate analyses. We also determined the influence of individual factors such as age on resource use and functional recovery.
2. Materials and methods
This study comprised a secondary analysis of an administrative database established by the Ministry of Health, Labour and Welfare (MHLW) in 2002. For this database, MHLW collected the data during the 4 months from July to October between 2002 and 2005 and during the 6 months from July to December since 2006. This database was used to develop a case-mix classification system and determine a per-diem payment system by our research team and the MHLW in cooperation with clinical experts14. It was also used to profile hospital performance and assess payments across 82 academic and 1346 community hospitals in 2008. These hospitals provide acute care, promote medical research, and teach medical students and postgraduate trainees. Data for 8,010,361 patients were compiled across 1006 hospitals that participated voluntarily in this research project. To equalize the study period, we selected data from participating hospitals during each 4-month period from July to October for 5 consecutive years up to fiscal year (FY) 2008. We restricted our analysis to patients aged ≥60 years with stroke, hip arthropathy or hip injury. This research was approved by the ethics committee of the University of Occupational and Environmental Health in Kitakyushu, Fukuoka, Japan.
2.1. Study variables
The study variables collected were age, sex, outcome at discharge, institutionalization, use of an ambulance, principal diagnosis, weighted comorbidity, functional status assessed by the Barthel index (BI), pre-existing arterial fibrillation/flutter (Af), procedure-related complications, deep vein thrombosis/pulmonary embolism, surgical procedures delivered, use or days of ventilation or rehabilitation administered, hospital teaching status (academic or community hospital), FY, length of hospital stay (LOS; days) and total hospital charge (TC; US$1=\100).
Age was stratified into three categories: 60–69 years, 70–79 years, and ≥80 years. Emergency admission was defined as transport by ambulance. TC included physician fees, instrument costs, laboratory or imaging test costs, and administration fees, and have been confirmed to be well correlated with costs (r=0.94)15.
The principal diagnoses were coded based on the International Classification of Diseases, 10th Revision. Stroke was subdivided into the following entities: transient ischemia (TIA; G45), lacunar status (G46), hemorrhage (I61), subarachnoid hemorrhage (SAH; I60), subdural hematoma (I62), infarction (I63) and reversible ischemic neurological deficits (I65–6) femur fracture (S72) and dislocation (S730, M2435, M2445), arthropathy of the femur head (M07$5, M12$5, M14$5, M16$, M19$5, M25$5).
Up to four comorbidities and four complications could be captured in this database. Weighted comorbidity status was calculated using the Charlson Comorbidity Index (CCI), which included dementia and cerebrovascular diseases16. Pre-existing Af was examined separately.
Cranial and orthopedic procedures applied for the study diseases were reviewed and included percutaneous endovascular interventions (e.g., coil implantation, angioplasty or thrombolysis), carotid endarterectomy, clipping, decompression craniotomy and evacuation of intracranial hematoma, internal fixation, prosthetic replacement, total hip replacement arthroplasty and displacement osteotomy.
Procedure-related complications were examined and included wound complications, hematoma or laceration, or disruption of the treated organs by instrumentation or manipulation, for example (T81–T87)17. The BI improvement score, determined as the BI at discharge minus BI at admission, was recorded into three categories: improvement, no change and deterioration9.
2.2. Statistical analysis
Categorical data (number and proportions) were compared by age category using Fisher’s exact test. Continuous data were compared by analysis of variance. Multiple logistic regression models determined the associations between study variables and surgical procedures. Multiple linear regression analysis was used to determine the variables affecting LOS, TC and BI improvement score. Statistical analyses were performed using SPSS version 16.0 (Chicago, IL, USA). P values were two-tailed with significance set at p<0.05.
3. Results
Across 151 study hospitals (40 academic and 111 community hospitals), we identified 35,566 stroke patients from 151 hospitals (40 academic and 111 community hospitals), 2537 hip arthropathy patients from 137 hospitals (40 academic and 97 community), and 7427 hip bone injury patients from 146 hospitals (39 academic and 107 community hospitals). There were 391 (1.1%) deaths in the stroke group, and 20 (0.3%) in the hip fracture group. The mean age, LOS, TC and BI improvement score were 74.6 years, 22.2 days, US$9157 and 15.6, respectively, in the stroke group; 71.3 years, 35.1 days, US$20,788 and 1.6, respectively, in the hip arthropathy group; and 81.4 years, 32.0 days, US$13,982 and 26.4, respectively, in the hip bone injury group.
Among the age categories, significant differences were observed for patient characteristics, patient care processes, outcomes and resource use. The rate of surgical procedures was lowest in the ≥80-year-old group, and was 18.8% for stroke, 87.2% for hip arthropathy and 89.3% for hip bone injury. The proportion of patients with BI deterioration was greater in the ≥80-year-old group, including 7.0% of stroke patients, 17.1% of hip arthropathy patients and 7.2% of hip bone injury patients. The mean improvement in BI was also smallest in patients aged ≥80 years old with stroke and hip injury (Table 1).
Table 1. Patient characteristics, care processes, outcomes and resource use for the three study diseases according to age category [n (%)].
| Stroke | Hip osteoarthropathy | Hip bone injury | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 60–69 | 70–79 | ≥80 | p | 60–69 | 70–79 | ≥ 80 | p | 60–69 | 70–79 | ≥ 80 | p | ||
| Overall | 10966 | 14361 | 10239 | 1035 | 1181 | 321 | 747 | 2078 | 4602 | ||||
| Age, mean±SD (y) | 64.9±2.9 | 74.4±2.9 | 85.1±4.3 | < 0.001 | 64.8±2.9 | 73.9±2.9 | 82.7±2.7 | < 0.001 | 65.2±2.9 | 75.3±2.8 | 86.8±4.7 | < 0.001 | |
| Sex | Male | 7605 (69.4) | 8874 (61.8) | 4373 (42.7) | < 0.001 | 134 (12.9) | 149 (12.6) | 44 (13.7) | 0.837 | 261 (34.9) | 543 (26.1) | 697 (15.1) | < 0.001 |
| Outcome | Deceased | 85 (0.8) | 141 (1) | 165 (1.6) | < 0.001 | 0.0 (0) | 0.0 (0) | 0.0 (0) | NR | 0 (0.0) | 3 (0.1) | 17 (0.4) | 0.085 |
| Discharge at home | 2317 (21.1) | 3891 (27.1) | 4170 (40.7) | < 0.001 | 156 (15.1) | 215 (18.2) | 82 (25.5) | < 0.001 | 276 (36.9) | 1057 (50.9) | 2936 (63.8) | < 0.001 | |
| Ambulance | 3824 (34.9) | 5203 (36.2) | 4753 (46.4) | < 0.001 | 10 (1.0) | 9 (0.8) | 13 (4) | < 0.001 | 342 (45.8) | 1017 (48.9) | 2193 (47.7) | 0.310 | |
| Diagnosis | |||||||||||||
| Diagnosis 1 | 815 (7.4) | 1105 (7.7) | 845 (8.3) | < 0.001 | NR | 485 (64.9) | 1388 (66.8) | 2770 (60.2) | < 0.001 | ||||
| Diagnosis 2 | 1378 (12.6) | 1776 (12.4) | 1329 (13) | — | 118 (15.8) | 487 (23.4) | 1589 (34.5) | — | |||||
| Diagnosis 3 | 617 (5.6) | 548 (3.8) | 234 (2.3) | — | 22 (2.9) | 32 (1.5) | 76 (1.7) | — | |||||
| Diagnosis 4 | 1529 (13.9) | 1649 (11.5) | 1159 (11.3) | — | 45 (6.0) | 65 (3.1) | 88 (1.9) | — | |||||
| Diagnosis 5 | 460 (4.2) | 1024 (7.1) | 941 (9.2) | — | 63 (8.4) | 78 (3.8) | 46 (1.0) | — | |||||
| Diagnosis 6 | 4546 (41.5) | 6452 (44.9) | 5243 (51.2) | — | 14 (1.9) | 28 (1.3) | 33 (0.7) | — | |||||
| Diagnosis 7 | 1621 (14.8) | 1807 (12.6) | 488 (4.8) | — | |||||||||
| CCI | |||||||||||||
| 1 | 2999 (27.3) | 4001 (27.9) | 2589 (25.3) | < 0.001 | 108 (10.4) | 172 (14.6) | 38 (11.8) | 0.130 | 154 (20.6) | 481 (23.1) | 923 (20.1) | < 0.001 | |
| 2 | 1470 (13.4) | 1938 (13.5) | 1530 (14.9) | — | 30 (2.9) | 33 (2.8) | 10 (3.1) | — | 85 (11.4) | 214 (10.3) | 367 (8.0) | — | |
| 3 or more | 626 (5.7) | 943 (6.6) | 593 (5.8) | — | 7 (0.7) | 10 (0.8) | 4 (1.2) | — | 48 (6.4) | 117 (5.6) | 167 (3.6) | — | |
| Atrial fibrillation or flutter | 634 (5.8) | 1243 (8.7) | 1249 (12.2) | < 0.001 | 9 (0.9) | 15 (1.3) | 8 (2.5) | 0.075 | 4 (0.5) | 45 (2.2) | 107 (2.3) | 0.007 | |
| Complication | 145 (1.3) | 190 (1.3) | 52 (0.5) | < 0.001 | 51 (4.9) | 60 (5.1) | 12 (3.7) | 0.604 | 21 (2.8) | 44 (2.1) | 104 (2.3) | 0.548 | |
| DVT, PE | 33 (0.3) | 37 (0.3) | 27 (0.3) | 0.790 | 28 (2.7) | 24 (2) | 7 (2.2) | 0.567 | 8 (1.1) | 43 (2.1) | 73 (1.6) | 0.146 | |
| Procedure | |||||||||||||
| Surgical procedure | 2211 (20.2) | 3024 (21.1) | 1908 (18.6) | <0.001 | 979 (94.6) | 1086 (92.0) | 280 (87.2) | <0.001 | 675 (90.4) | 1885 (90.7) | 4108 (89.3) | 0.168 | |
| Ventilation | 530 (4.8) | 531 (3.7) | 253 (2.5) | <0.001 | 1 (0.1) | 0 (0.0) | 0 (0.0) | 0.484 | 1 (0.1) | 17 (0.8) | 20 (0.4) | 0.039 | |
| Rehabilitation | 4449 (40.6) | 6068 (42.3) | 4948 (48.3) | <0.001 | 820 (79.2) | 904 (76.5) | 226 (70.4) | 0.004 | 522 (69.9) | 1424 (68.5) | 3051 (66.3) | 0.056 | |
| Teaching status | |||||||||||||
| Community | 7281 (66.4) | 9857 (68.6) | 7987 (78.0) | <0.001 | 496 (47.9) | 608 (51.5) | 198 (61.7) | <0.001 | 595 (79.7) | 1746 (84) | 4219 (91.7) | < 0.001 | |
| Academic | 3685 (33.6) | 4504 (31.4) | 2252 (22.0) | — | 539 (52.1) | 573 (48.5) | 123 (38.3) | — | 152 (20.3) | 332 (16) | 383 (8.3) | — | |
| Fiscal year | |||||||||||||
| 2004 | 2273 (20.7) | 2738 (19.1) | 1791 (17.5) | < 0.001 | 203 (19.6) | 191 (16.2) | 43 (13.4) | 0.024 | 143 (19.1) | 351 (16.9) | 769 (16.7) | 0.046 | |
| 2005 | 2548 (23.2) | 3301 (23.0) | 2212 (21.6) | — | 272 (26.3) | 308 (26.1) | 86 (26.8) | — | 184 (24.6) | 511 (24.6) | 1020 (22.2) | — | |
| 2006 | 2814 (25.7) | 3767 (26.2) | 2736 (26.7) | — | 274 (26.5) | 317 (26.8) | 81 (25.2) | — | 171 (22.9) | 494 (23.8) | 1083 (23.5) | — | |
| 2007 | 1766 (16.1) | 2411 (16.8) | 1800 (17.6) | — | 148 (14.3) | 165 (14.0) | 63 (19.6) | — | 112 (15.0) | 371 (17.9) | 832 (18.1) | — | |
| 2008 | 1565 (14.3) | 2144 (14.9) | 1700 (16.6) | — | 138 (13.3) | 200 (16.9) | 48 (15.0) | — | 137 (18.3) | 351 (16.9) | 898 (19.5) | — | |
| Improvement of BI | |||||||||||||
| Deterioration | 336 (3.1) | 686 (4.8) | 716 (7.0) | < 0.001 | 139 (13.4) | 177 (15.0) | 55 (17.1) | < 0.001 | 36 (4.8) | 115 (5.5) | 331 (7.2) | 0.028 | |
| No change | 6394 (58.3) | 7847 (54.6) | 5130 (50.1) | — | 747 (72.2) | 752 (63.7) | 185 (57.6) | — | 225 (30.1) | 594 (28.6) | 1325 (28.8) | — | |
| Improvement | 4236 (38.6) | 5828 (40.6) | 4393 (42.9) | — | 149 (14.4) | 252 (21.3) | 81 (25.2) | — | 486 (65.1) | 1369 (65.9) | 2946 (64.0) | — | |
| BI improvement score at admission, mean±SD | 67.3±40.1 | 60.7±41.2 | 42.4±41.1 | < 0.001 | 95±13.7 | 93.2±14.0 | 85.3±23.8 | < 0.001 | 43.2±37.1 | 35.9±35 | 27.6±33.1 | < 0.001 | |
| BI improvement score at discharge, mean±SD | 84±31.1 | 76.3±36.0 | 56.8±41.4 | < 0.001 | 95.9±10.6 | 95.1±10.1 | 88.4±19.9 | < 0.001 | 76.1±31.5 | 66.6±33.8 | 51±34.5 | < 0.001 | |
| BI improvement score, mean±SD | 16.7±30.4 | 15.5±29.7 | 14.4±28.7 | < 0.001 | 0.8±13.8 | 2.0±13.0 | 3.1±17.4 | 0.026 | 32.9±34.5 | 30.7±34 | 23.4±30.8 | < 0.001 | |
| Resource use | |||||||||||||
| LOS, days,mean±SD | 20.4±20 | 22.1±21.9 | 24.3±23.5 | < 0.001 | 34.7±17.0 | 35.5±19.6 | 35.1±18 | 0.575 | 32±23.2 | 33.9±21.8 | 31.2±19.2 | < 0.001 | |
| TC, $,mean±SD | 9330±10344 | 9262±9840 | 8822±8343 | < 0.001 | 21226±7419 | 20689±7869 | 19739±7782 | 0.008 | 13807±8539 | 14917±7731 | 13589±6276 | < 0.001 | |
| Ventilation days, mean±SD | 7.1±11.0 | 7.9±13.7 | 8.4±14.9 | 0.382 | NR | 4.0±5.2 | 5.3±7.8 | 5.6±6.5 | 0.936 | ||||
| Initiation day of rehabilitation, mean±SD | 7.7±10.0 | 7.9±11.0 | 7.2±11.5 | 0.004 | 13.1±16.6 | 14.1±19.3 | 13±16.3 | 0.432 | 13.5±18.4 | 13±17.3 | 10.4±13.9 | < 0.001 | |
| Rehabilitation days, mean±SD | 13.2±16.0 | 14.8±17.3 | 16.3±17.2 | < 0.001 | 14.7±13.1 | 15.2±13.2 | 16.4±13.2 | 0.239 | 14.4±14.9 | 16.5 ± 16.1 | 15.5±13.5 | 0.013 | |
Surgical procedures are less likely to be performed in those aged ≥80 years, with odds ratios of 0.722 (95% confidence interval: 0.656–0.796) for stroke, 0.572 (0.356–0.917) for hip arthropathy and 0.726 (0.551–0.955) for hip bone injury. FY was a significant determinant for the use of surgical procedures, with odds ratios of 1.076 (1.048–1.105) for stroke, 1.300 (1.144–1.478) for hip arthropathy and 1.071 (1.011–1.134) for hip bone injury (Table 2).
Table 2. Logistic regression analysis of factors associated with the use of surgical procedures for the three study diseases.
| Stroke | Hip arthropathy | Hip bone injury | ||||
|---|---|---|---|---|---|---|
| OR | 95% CI | OR | 95% CI | OR | 95% CI | |
| Age (reference 60–69 y) | ||||||
| 70–79 y | 0.972 | 0.898–1.052 | 0.636 | 0.447–0.906 | 0.953 | 0.713–1.274 |
| ≥80 y | 0.722 | 0.656–0.796 | 0.572 | 0.356–0.917 | 0.726 | 0.551–0.955 |
| Male | 1.073 | 0.997–1.155 | 0.812 | 0.521–1.264 | 0.710 | 0.592–0.852 |
| Ambulance | 0.977 | 0.899–1.061 | 0.079 | 0.035–0.178 | 1.534 | 1.311–1.795 |
| Principal diagnosis (reference: Diagnosis 1) | ||||||
| Diagnosis 2 | 3.896 | 2.711–5.600 | NR | 3.354 | 1.981–5.679 | |
| Diagnosis 3 | 178.850 | 124.121–257.712 | 2.514 | 1.471–4.296 | ||
| Diagnosis 4 | 12.377 | 8.726–17.556 | 3.231 | 1.467–7.116 | ||
| Diagnosis 5 | 1045.988 | 718.989–1521.706 | 2.279 | 1.164–4.460 | ||
| Diagnosis 6 | 5.304 | 3.758–7.487 | 3.899 | 1.878–8.097 | ||
| Diagnosis 7 | 38.677 | 27.325–54.745 | ||||
| BI at admission | 0.989 | 0.988–0.990 | 1.022 | 1.015–1.03 | 0.998 | 0.996–1.000 |
| CCI (reference: zero) | ||||||
| 1 | 1.282 | 1.183–1.390 | 1.107 | 0.685–1.789 | 0.967 | 0.796–1.173 |
| 2 | 1.354 | 1.226–1.495 | 1.108 | 0.422–2.911 | 0.823 | 0.635–1.067 |
| 3 or more | 1.478 | 1.291–1.692 | 0.437 | 0.133–1.442 | 0.757 | 0.537–1.069 |
| Atrial fibrillation or flutter | 1.096 | 0.968–1.240 | 0.711 | 0.198–2.550 | 1.090 | 0.632–1.880 |
| Hospital (reference: community) | ||||||
| Academic | 1.206 | 1.121–1.298 | 1.231 | 0.897–1.688 | 0.555 | 0.450–0.685 |
| Fiscal year 2004–2009 | ||||||
| year by year | 1.076 | 1.048–1.105 | 1.300 | 1.144–1.478 | 1.071 | 1.011–1.134 |
| HL goodness of fit model | 0.070 | 0.190 | 0.585 | |||
After adjusting for the potential confounding effects of demographic and clinical variables, stroke in the 70–79-year-old group was significantly associated with longer LOS, higher TC and smaller BI improvement score. For hip arthropathy, longer LOS, but no change in BI improvement score, were observed in the 70–79-year-old group; there were no differences in TC among the three age groups. For hip bone injury, the 70–79–year-old group had longer LOS, higher TC and a lower BI improvement score. Among the conditions included here, surgical procedures or ventilation increased LOS or TC the most, with the exception of subarachnoid hemorrhage, which accounted for the highest TC (Table 3).
Table 3. Factors associated with length of stay (LOS), total charge (TC; $) and Barthel index (BI) improvement score for the three study diseases.
| Independent variables | Stroke | Hip arthropathy | Hip bone injuries | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| LOS | TC | BI improvement score | LOS | TC | BI improvement score | LOS | TC | BI improvement score | ||||||||||
| B, SE | p | B, SE | p | B, SE | p | B, SE | p | B, SE | p | B, SE | p | B, SE | p | B, SE | p | B, SE | p | |
| Intercept | 16.8, 0.5 | †† | 4299, 173 | †† | 55.8, 0.7 | †† | 30, 2.4 | †† | 7158, 804 | †† | 59.7, 1.5 | †† | 39.8, 2.4 | †† | 8339, 749 | †† | 40.3, 3.4 | †† |
| Age (reference: 60–69 years) | ||||||||||||||||||
| 70–79 years | 0.9, 0.2 | †† | 26, 78 | — | −3.2, 0.3 | †† | 1.8, 0.7 | † | 74, 234 | — | 0.0, 0.4 | — | 2.8, 0.8 | † | 996, 252 | †† | −3.3, 1.1 | † |
| ≥ 80 years | 0.7, 0.3 | † | −723, 90 | †† | −10.8, 0.3 | †† | 2.4, 1.1 | † | 7, 359 | — | −3.6, 0.7 | †† | 1.9, 0.8 | † | 280, 242 | — | −12.1, 1.1 | †† |
| Male | −0.8, 0.2 | †† | −39, 69 | — | 1.9, 0.3 | †† | −1.8, 1 | — | −251, 328 | — | −0.9, 0.6 | — | 0.3, 0.6 | — | 17, 173 | — | −2, 0.8 | † |
| Institutionalization | 7.9, 0.3 | †† | 2716, 86 | †† | −23.8, 0.3 | †† | −4, 0.9 | †† | 402, 291 | — | −5.2, 0.5 | †† | −8.4, 0.5 | †† | −1495, 145 | †† | −16.3, 0.7 | †† |
| Ambulance | 0.2, 0.2 | 818, 76 | †† | 1.8, 0.3 | †† | −10.4, 3.1 | † | −2573, 1022 | † | 6.2, 1.9 | † | 1, 0.4 | † | 349, 138 | † | 5.1, 0.6 | †† | |
| Principal Diagnosis (reference: Diagnosis 1) | ||||||||||||||||||
| Diagnosis 2 | 4.6, 0.4 | †† | 1592, 152 | †† | −2.5, 0.6 | †† | ∗∗∗ | −11.8, 2.2 | †† | −1924, 683 | † | 5.9, 3.1 | — | |||||
| Diagnosis 3 | 6, 0.7 | †† | 13271, 225 | †† | 10.1, 0.9 | †† | −13.4, 2.2 | †† | −4447, 690 | †† | 3, 3.1 | — | ||||||
| Diagnosis 4 | 4.7, 0.5 | †† | 1199, 160 | †† | −4.6, 0.6 | †† | −5.7, 2.8 | † | −2395, 848 | † | 2.2, 3.8 | — | ||||||
| Diagnosis 5 | −16.7, 0.6 | †† | −9007, 197 | †† | 10.4, 0.8 | †† | −2.3, 2.6 | — | −1297, 793 | — | 4.1, 3.6 | — | ||||||
| Diagnosis 6 | 5.4, 0.4 | †† | 1902, 131 | †† | −2.3, 0.5 | †† | −29, 2.6 | †† | −11912, 802 | †† | 7.9, 3.6 | † | ||||||
| Diagnosis 7 | −0.1, 0.5 | — | 838, 158 | †† | −2.2, 0.6 | †† | ||||||||||||
| BI at admission | −0.1, 0 | †† | −23, 1 | †† | −0.5, 0 | †† | 0, 0 | −6, 2 | † | −0.5, 0 | †† | |||||||
| CCI (reference: 0) | ||||||||||||||||||
| 1 | 0.9, 0.2 | †† | 489, 77 | †† | 0, 0.3 | −0.2, 0 | †† | −52, 7 | †† | −0.6, 0 | †† | 1.1, 0.6 | — | 558, 172 | † | −1, 0.8 | ||
| 2 | 2.2, 0.3 | †† | 1001, 98 | †† | −1, 0.4 | † | 0.7, 1 | — | −58, 331 | −0.2, 0.6 | — | 3, 0.8 | †† | 1689, 244 | †† | −2.1, 1.1 | ||
| 3 or more | 3.3, 0.4 | †† | 1471, 140 | †† | −0.7, 0.5 | — | 5.4, 2 | † | 2548, 655 | †† | −3.5, 1.2 | † | 2.9, 1.1 | † | 1945, 336 | †† | −4, 1.5 | † |
| Atrial fibrillation or flutter | 3, 0.3 | †† | 1100, 117 | †† | −1, 0.4 | † | 12.8, 3.6 | †† | 2440, 1208 | † | −7.7, 2.2 | † | 1.5, 1.5 | — | 740, 474 | −4.7, 2.1 | † | |
| Complication | −3.2, 0.9 | † | 1101, 320 | † | 2.9, 1.2 | † | −2.6, 2.9 | — | 790, 982 | — | −1, 1.8 | — | 3.5, 1.5 | † | 2346, 456 | †† | −1.1, 2.1 | — |
| DVT, PE | 8.3, 1.8 | †† | 2088, 618 | † | −3.3, 2.4 | — | 6.5, 1.5 | †† | 2701, 512 | †† | 2.3, 0.9 | † | 2, 1.7 | — | 2117, 530 | †† | −2.6, 2.4 | — |
| Surgical procedure | 18.1, 0.3 | †† | 11156, 109 | †† | −7, 0.4 | †† | 7.3, 2.2 | † | 2976, 722 | †† | −0.1, 1.3 | — | 8.8, 0.7 | †† | 8685, 229 | †† | 11.2, 1 | †† |
| Ventilation | 6.3, 0.6 | †† | 8332, 190 | †† | −8.7, 0.7 | †† | 24.5, 1.4 | †† | 17764, 455 | †† | 0.6, 0.8 | — | 16.2, 3.1 | †† | 11986, 950 | †† | −14.2, 4.3 | † |
| Rehabilitation | 9.3, 0.2 | †† | 3780, 75 | †† | 1.7, 0.3 | †† | 4.7, 0.9 | †† | 3323, 294 | †† | −0.5, 0.5 | — | 6.9, 0.6 | †† | 2333, 176 | †† | 7.3, 0.8 | †† |
| Hospital (reference: community) | ||||||||||||||||||
| Academic | 0.5, 0.2 | † | 877, 74 | †† | −2.2, 0.3 | †† | 2.5, 0.7 | †† | 1313, 223 | †† | −1.5, 0.4 | †† | −0.2, 0.7 | — | 885, 220 | †† | −1.3, 1 | — |
| Fiscal year 2004–09 | ||||||||||||||||||
| year by year | −2.3, 0.1 | †† | −461, 26 | †† | 0.6, 0.1 | †† | −2.6, 0.3 | †† | −797, 91 | †† | 0.5, 0.2 | † | −3.2, 0.2 | †† | −523, 61 | †† | −1.2, 0.3 | †† |
| F-test for the model; | †† | †† | †† | < 0.001 | < 0.001 | < 0.001 | < 0.001 | < 0.001 | < 0.001 | |||||||||
| Coefficient of determination | 0.344 | 0.600 | 0.389 | 0.218 | 0.501 | 0.490 | 0.146 | 0.306 | 0.335 | |||||||||
4. Discussion
This study shows the independent effects of age and surgical procedures on resource use and functional recovery of patients with stroke, hip arthropathy and bone injury. A marked age disparity in medical care was observed because the use of surgical procedures was less in patients aged ≥80 years old. The use of surgical procedures increased each year among the three study populations. After adjusting for other covariates, age had a small, if any, effect on LOS and TC, and the effect of age was much less than that of surgical procedures or ventilation on LOS and TC. Advancing age showed less restoration of functional recovery, except in the 70–79-year-old patients with hip arthropathy.
The LE in G7 countries is approximately 80 years, and the low fertility rate is another phenomenon that is skewing the age distribution18. Because of the economic effects of fertility declines for individuals, companies and governments are also affected, and stakeholders must consider the sustainability of healthcare systems and maintain the balance between healthcare expenditure and gross domestic product. To compensate for the increase in healthcare costs in countries with social insurance systems, the older generation is expected to become more involved in social activity, possibly against their wishes. Studies on age disparity, in access to geriatric medicine, have examined efficiency or equity9, 11. As costly but less-invasive innovations have undoubtedly benefited older patients, the efficiency of geriatric medicine should be evaluated and discussed. For older people to maintain their involvement in social activity in healthier conditions, equity in delivering appropriate care and obtaining functional outcomes in acute care settings should be assured, because Kugler et al reported that the resulting functional recovery depended on the extent of the initial disability and not on age9. Very few of the studies on age disparity or quality of geriatric medicine, simultaneously considered the surgical procedure used and critical care provided, even though these factors are expected to affect functional recovery or resource use. The strength of our study was that we measured the effects of age category and surgical procedures in diseases common in older people. Among those aged 70–79 years old, age is not necessarily the limiting factor for the use of surgical procedures, particularly in patients with hip arthropathy, because resource use and functional recovery were similar to those in patients aged 60–69 years.
Among the diseases included in this study, there seemed to be a marked variation in the balance between resource use and BI improvement in each age group because the size effect for LOS, TC and BI improvement score varied (Table 3). Physicians should recognize that there might be some scope for more widespread use of surgical procedures and more convalescence in patients aged 70–79 years with hip arthropathy, if the physical conditions permit such activities, because they received fewer procedures than patients in the 60–69 year group, but obtained comparable functional recovery (Table 2, Table 3). To maintain the social activity of elderly people, stakeholders should acknowledge the possible degree of functional recovery of these individuals. In addition to monitoring the quality of physiologic recovery achieved through medical care, policy-makers should consider and establish priorities for implementing quality improvement initiatives among several case-mix groups. Based on the results of this study, stakeholders should consider quality improvement initiatives aimed at 70–79-year-old patients with hip arthropathy, and thus overcome the disparity in care in this population. Another justification of this initiative was that the BI improvement score differed among the study diseases with advancing FY. Hip bone injury was associated with less BI improvement, whereas the other two diseases provided better BI improvement despite reductions in LOS. The Organization for Economic Co-operation and Development (OECD) has acknowledged the dramatic decrease in average LOS in Japanese acute care hospitals. Most of them were associated with the introduction of the per-diem cost containment payment scheme, which is relatively highly reimbursed in the earlier admission periods; thus, stakeholders should assess whether appropriate care delivery for hip bone injury is diminished by inappropriate LOS1, 14. By contrast, care delivery for patients aged ≥80 years could be left to the preference of the patients or physicians, because of the limited evidence for clinical benefits of the care process. This may be because of poor residual functional capacity and the fact that these individuals are less able to tolerate the stress associated with hospitalization or invasive procedures, as compared with the younger age groups in this study.
Several limitations should be mentioned. Firstly, information was obtained from discharged patients for only 4-month periods each year, which may limit the generalizability of the results. However, this may be overcome in future analyses because the MHLW are now planning to collect data for the entire year. This study also lacked analyses of clinical or quality of life information after discharge, such as the presence of multiple system bone injury, as evaluated using the Injury Severity Score, or the recovery of social functioning determined by the Short Form 366, 19. However, this database includes the former information, and the registries of relevant societies could resolve this limitation, because most hospitals participating in this case-mix project also contribute to these registries21. Secondly, the duration of hospitalization in Japan is generally two to three times longer than that in western countries1, 20. Japanese hospitals generally provide wound management, rehabilitation and nursing home services, in addition to acute medical care. Accordingly, our results might better reflect the real costs that are incurred during the entire care process. Indeed, the OECD recognized that the longer LOS observed in Japanese acute care hospitals was at least partly due to the broader differentiation of ‘acute care’ compared with the definition used in other OECD countries20. Nevertheless, the longer hospitalization in Japan might be another justification for economic evaluations, similar to this kind of study.
In conclusion, this study revealed marked age disparities in the use of surgical procedures, LOS, TC and functional recovery. The effect of age was small but significant, except for hip arthropathy, where the functional outcome was similar between the groups aged 60–69 years and 70–79 years. To maintain or promote social activities among older people, the stakeholders should acknowledge the variations in quality of geriatric acute care and promote quality improvement initiatives that target individuals aged 70–79 years, particularly those with hip arthropathy.
Acknowledgments
This study was funded in part by Grants-in-Aid for Research on Policy Planning and Evaluation (Japanese Ministry of Health, Labour and Welfare, H19 Seisaku-sitei 001).
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PII: S1873-9598(11)00104-9
doi:10.1016/j.ijge.2011.09.033
© 2011 Published by Elsevier Inc.
Volume 5, Issue 3 , Pages 139-145, September 2011
