HOS HighlightsHOS Highlights Coexisting Illness and Heart Disease Among Elderly

Medicare Managed Care Enrollees Arlene S. Bierman, M.D., M.S.

INTRODUCTION

High rates of comorbidity present a chal­lenge in providing care to elderly Medicare managed care enrollees. Comorbidity or the presence of coexisting illness strongly influences utilization, costs, and outcomes of health care. Ischemic heart disease (IHD) and congestive heart failure (CHF) are leading causes of morbidity and mor­tality among Medicare beneficiaries. Both have been the targets of successful quality improvement initiatives by CMS (Jencks, Huff, and Cuerdon, 2003). Medicare HEDIS® has targeted improved manage­ment of hypertension and diabetes, as well as smoking cessation, all important risk factors for IHD and CHF. The impact of dis­ease management programs on outcomes for these conditions is being evaluated in CMS demonstration projects (Haffer et al., 2003). Additional improvements in quality and outcomes of care for beneficiaries with these conditions may be achieved by improving management of common coex­isting illnesses.

The large sample size of the Medicare Health Outcomes Survey (HOS) affords an unprecedented opportunity to look at the prevalence and patterns of coexisting ill­ness among enrollees with IHD and CHF. The author is with Faculities of Medicine and Nursing, University of Toronto, and Inner City Health Research Unit, St. Michael’s Hospital, Toronto, Canada. The views expressed in this article are those of the author and do not necessarily reflect those of the University of Toronto, St. Michael’s Hospital, or the Centers for Medicare & Medicaid Services (CMS).

The HOS instrument contains items for assessing physical and mental health sta­tus, chronic conditions, clinical symptoms, and demographic information (National Committee for Quality Assurance, 2000). The following figures are based on the responses of 167,854 community-dwelling individuals age 65 or over enrolled in Medicare managed care who participated in the HOS Cohort I Baseline Survey. The sample is 58 percent female and includes 31,315 respondents who report having IHD, and 11,239 respondents who report having CHF.

Enrollees with IHD or CHF have lower incomes and lower levels of educational attainment than the overall M+C enrollee population, placing them at increased risk of encountering both financial and non­financial barriers to care. They also report higher levels of comorbidity, and a higher prevalence of common chronic conditions. Nine out of ten enrollees with these condi­tions report having three or more chronic conditions, and they report having a mean of five chronic conditions. In addition to hypertension and diabetes, risk factors for heart disease, there is a high prevalence of chronic non-fatal disabling conditions that can affect outcomes and compliance with treatments including arthritis, severe low-back pain, urinary incontinence, and sen­sory impairments. The high prevalence of depressed mood underscores the need to also address mental health issues in these

HEALTH CARE FINANCING REVIEW/Summer 2004/Volume 25, Number 4 105

beneficiaries. In addition, the burden of coexisting illness varies by sex, race/eth­nicity, and socioeconomic status. Females, African-American, Latino, and socioeco­nomically disadvantaged enrollees report a higher burden of coexisting illness.

Future efforts should focus on imple­menting and evaluating models of care for beneficiaries with heart disease that address the coexisting illnesses present in these patients. Opportunities also exist for prevention. Insights from the HOS survey can inform the development of compre­hensive models of care.

HEALTH CARE FINANCING REVIEW/Summer 2004/Volume 25, Number 4 106

Figure 1

Differences in Income and Education Among Elderly Medicare+Choice (M+C) Enrollees with IHD or CHF Compared to All M+C Enrollees: 1998

50 All

Male 44 Female 42

39 39 40

35

32 32 30 31 30

30 26

cP

eren

t

22 20

20 17 15

13

9 10 9

0

All IHD CHF All IHD CHF

Annual Household Income Less Than Less Than 12 Years of Education

$10,000

NOTE: IHD is ischemic heart disease; CHF is congestive heart failure.

SOURCE: Centers for Medicare & Medicaid Services: 1998 Medicare Health Outcome Survey, Cohort Ι Baseline Measurement Data Set.

• Females are much more likely than males to report annual household incomes less than $10,000. Twenty percent of all females compared to nine percent of males are in this income category.

• Enrollees with CHF are more likely to report annual household incomes less than $10,000 then the overall M+C enrollee population. Nearly one in three females with CHF are in this income category.

• Enrollees with IHD and CHF are more likely not to have completed high school than the overall M+C enrollee population. Thirty-five percent of enrollees with IHD, and 42 per­cent with CHF have not completed high school.

• Females with IHD and CHF are more likely not to have completed high school than males reporting these conditions.

HEALTH CARE FINANCING REVIEW/Summer 2004/Volume 25, Number 4 107

Figure 2

Differences in the Percent of Elderly Medicare+Choice (M+C) with IHD and CHF Who Report Three or More Chronic Conditions Compared to All M+C Enrollees: 1998

100 All 92 92 9390 Male 90 86

Female 82

80

70

Per

cen

t

60

47 48 50 45

40

30

20

10

0

All IHD CHF

NOTE: IHD is ischemic heart disease; CHF is congestive heart failure.

SOURCE: Centers for Medicare & Medicaid Services: 1998 Medicare Health Outcome Survey, Cohort Ι Baseline Measurement Data Set.

• Comorbidity among Medicare managed care enrollees is common, with 47 percent of respondents reporting three or more chronic conditions.

• Enrollees with IHD and CHF are much more likely to report having three or more chron­ic conditions than the overall M+C enrollee population.

• Eighty-six percent of enrollees with IHD, and 92 percent of enrollees with CHF report having three or more chronic conditions.

HEALTH CARE FINANCING REVIEW/Summer 2004/Volume 25, Number 4 108

Fig

ure

3

Dif

fere

nce

s in

th

e P

erce

nt

of

Eld

erly

Med

icar

e+C

ho

ice

En

rolle

es w

ith

IHD

an

d C

HF

Rep

ort

ing

Dia

bet

es, S

tro

ke, o

r C

OP

D/A

sth

ma

Co

mp

ared

to

All

M+C

En

rolle

es:

1998

Percent

40

Mal

e34

35

Fem

ale

31

30

26

25

25

25

2522

20

20

19

18

17

17

16

14

15

13

12

9 10

7

5 0

All

IHD

C

HF

A

ll IH

D

CH

F

All

IHD

C

HF

Dia

bete

s S

trok

e A

sthm

a/C

OP

D

NO

TE

: IH

D is

isch

emic

hea

rt d

isea

se; C

HF

is c

onge

stiv

e he

art f

ailu

re; a

nd C

OP

D is

chr

onic

obs

truc

tive

pulm

onar

y di

seas

e.

SO

UR

CE

: Cen

ters

for

Med

icar

e &

Med

icai

d S

ervi

ces:

199

8 M

edic

are

Hea

lth O

utco

me

Sur

vey,

Coh

ort Ι

Bas

elin

e M

easu

rem

ent D

ata

Set

.

•

Dia

bete

s, a

ris

k fa

ctor

s fo

r IH

D a

nd C

HF,

is m

uch

mor

e pr

eval

ent a

mon

g en

rolle

es r

epor

ting

thes

e co

nditi

ons.

•

One

-qua

rter

of m

ales

and

one

-thir

d of

fem

ales

rep

ortin

g IH

D o

r C

HF

also

rep

ort a

his

tory

of d

iabe

tes.

•

In a

dditi

on,

abou

t tw

o-th

irds

of

mal

es a

nd t

hree

-qua

rter

s of

fem

ales

rep

ortin

g IH

D o

r C

HF

also

rep

ort

a hi

stor

y of

hy

pert

ensi

on, a

noth

er r

isk

fact

or fo

r th

ese

cond

ition

s (d

ata

not s

how

n).

•

Str

oke

and

CO

PD/a

sthm

a ar

e m

ore

prev

alen

t am

ong

enro

llees

with

IH

D o

r C

HF

than

in

the

over

all

M+C

enr

olle

e po

pula

tions

.

HEALTH CARE FINANCING REVIEW/Summer 2004/Volume 25, Number 4 109

Figure 4

Differences in the Percent of Elderly Medicare+Choice (M+C) with IHD and CHF Reporting Low Back Pain Compared to All M+C Enrollees: 1998

Per

cen

t 30 All

Male 26 Female

25

22 22

20 18 17

15 13

12 11

9 10

5

0

All IHD CHF

NOTE: IHD is ischemic heart disease; CHF is congestive heart failure.

SOURCE: Centers for Medicare & Medicaid Services: 1998 Medicare Health Outcome Survey, Cohort Ι Baseline Measurement Data Set.

• Arthritis and severe low back pain may place a barrier to complying with recommenda-tions to exercise and are commonly reported by all M+C enrollees. However, they are more often reported by enrollees with CHF and IHD, and more prevalent in females.

• Roughly one-half of males and two-thirds of females reporting IHD or CHF also report having arthritis (data not shown).

• One in five enrollees with CHF report having low back pain that interferes with their activities all or most of the time.

110 HEALTH CARE FINANCING REVIEW/Summer 2004/Volume 25, Number 4

Figure 5

Differences in the Percent of Elderly Medicare+Choice (M+C) Enrollees with IHD and CHF Reporting Depressed Mood Compared to All M+C Enrollees: 1998

Per

cen

t 30 All 28

Male 26 Female 24 24 25

19 20

16 15 15 13

10 10

5

0

All IHD CHF

NOTE: IHD is ischemic heart disease; CHF is congestive heart failure.

SOURCE: Centers for Medicare & Medicaid Services: 1998 Medicare Health Outcome Survey, Cohort Ι Baseline Measurement Data Set.

• Depressed mood is prevalent in Medicare managed care enrollees. One of every eight enrollees responded yes when asked if…In the past year, have you felt depressed or sad much of the time?

• Enrollees reporting IHD and CHF are much more likely to report having a depressed mood than the overall M+C enrollee population. Nineteen percent of enrollees with IHD and 26 percent of enrollees with CHF report depressed mood.

• Females are more likely than males to report having a depressed mood.

HEALTH CARE FINANCING REVIEW/Summer 2004/Volume 25, Number 4 111

Figure 6

Differences in the Percent of Elderly Medicare+Choice (M+C) Enrollees with IHD and CHF Reporting Urinary Incontinence Compared to All M+C Enrollees: 1998

Per

cen

t 45 All

41Male

40 38 Female 37

35 32 32

30 28 27

25 25

22

20

15

10

5

0

All IHD CHF

NOTE: IHD is ischemic heart disease; CHF is congestive heart failure.

SOURCE: Centers for Medicare & Medicaid Services: 1998 Medicare Health Outcome Survey, Cohort Ι Baseline Measurement Data Set.

• Urinary incontinence, can place a barrier to both compliance with diuretic therapy and recommendations to exercise, is commonly reported by all M+C enrollees. Urinary incontinence is more often reported by enrollees with CHF and IHD, and more prevalent in females.

• Twenty-seven percent of males with IHD and 32 percent of males with CHF report uri­nary incontinence.

• Thirty-eight percent of females with IHD and 41 percent of females with CHF report uri­nary incontinence.

HEALTH CARE FINANCING REVIEW/Summer 2004/Volume 25, Number 4 112

Figure 7

Differences in the Percent of Elderly Medicare+Choice (M+C) Enrollees with IHD and CHF Reporting Sensory Impairment Compared to All M+C Enrollees: 1998

25 Male

Female

Per

cen

t

20

15

10

5

0

All IHD CHF All IHD CHF

Hearing Impairment Visual Impairment

NOTE: IHD is ischemic heart disease; CHF is congestive heart failure.

SOURCE: Centers for Medicare & Medicaid Services: 1998 Medicare Health Outcome Survey, Cohort Ι Baseline Measurement Data Set.

• Difficulty hearing or hearing impairment, and difficulty seeing or visual impairment are more prevalent among enrollees with IHD and CHF and report these conditions more than the overall M+C enrollee population.

• Hearing impairment is more prevalent in males than females, and visual impairment is more prevalent in females than males.

• One in five males with CHF also report hearing impairment, and one in seven females with CHF also report visual impairment.

HEALTH CARE FINANCING REVIEW/Summer 2004/Volume 25, Number 4 113

Figure 8

Differences in Physical Functioning as Measured by the SF-36® PCS Among Elderly Medicare+Choice (M+C) Enrollees with IHD and CHF Reporting Compared to All M+C Enrollees: 1998

SF

-36®

PC

S

46 All

44 Male 44 43 Female

42 42

40 40

38 38

36 36

35

34 34

32 32

30

All IHD CHF

NOTE: IHD is ischemic heart disease; CHF is congestive heart failure; and PCS is physical component summary.

SOURCE: Centers for Medicare & Medicaid Services: 1998 Medicare Health Outcome Survey, Cohort Ι Baseline Measurement Data Set.

• Enrollees reporting IHD have lower scores on the SF-36® PCS score or worse function-al status than the overall M+C enrollee population.

• Enrollees with CHF have lower scores on the SF-36® PCS score than individuals report-ing IHD.

• Females with IHD and CHF have lower scores on the SF-36® PCS score than the males. • Females reporting CHF have a mean SF-36® PCS score of 32, one standard deviation below that of the overall M+C enrollee population.

114 HEALTH CARE FINANCING REVIEW/Summer 2004/Volume 25, Number 4

Differences in

45

40

35

30

Figure 9

Percent of Enrollees Age 65 Reporting Both CHF and Diabetes by Race/Ethnicity, Income, and Education: 1998

43 Diabetes

39

35 34 32

ent 25

cP

er 20

15

10

5

0

All Non-Hispanic Black Hispanic or Less Than A Poor Less or African American Spanish High School Than $10,000

Education Income NOTE: CHF is congestive heart failure.

SOURCE: Centers for Medicare & Medicaid Services: 1998 Medicare Health Outcome Survey, Cohort Ι Baseline Measurement Data Set.

• Diabetes is a common comorbidity among enrollees reporting CHF. There are variations in the prevalence of diabetes by race/ethnicity and socioeconomic status.

• Forty-three percent of non-hispanic black or African-American enrollees and 39 percent of Hispanic enrollees reporting CHF also report having diabetes.

• Thirty-five percent of enrollees with annual household incomes below $10,000 reporting CHF also report having diabetes.

HEALTH CARE FINANCING REVIEW/Summer 2004/Volume 25, Number 4 115

Figure 10

Differences in Mean Number of Chronic Conditions Among Enrollees Age 65 Reporting CHF, by Race/Ethnicity, Income, and Education: 1998

Mea

n

5.6

5.48 5.5 5.44

5.4 5.31

5.29 5.3

5.2

5.1 5.01

5

4.9

4.8

4.7

All Non-Hispanic Black Hispanic or Less Than A Poor Less or African American Spanish High School Than $10,000

Education Income NOTE: CHF is congestive heart failure.

SOURCE: Centers for Medicare & Medicaid Services: 1998 Medicare Health Outcome Survey, Cohort Ι Baseline Measurement Data Set.

• Enrollees reporting CHF report a mean of five comorbid conditions. There are variations in the mean number of comorbid conditions by race/ethnicity and socioeconomic status.

• Non-hispanic black or African-American enrollees and Hispanics enrollees reporting CHF report more coexisting illness.

• Enrollees with annual household incomes less than $10,000 and those who have not com­pleted high school also report more coexisting illnesses.

HEALTH CARE FINANCING REVIEW/Summer 2004/Volume 25, Number 4 116

ACKNOWLEDGMENTS

The author would like to thank Samuel J. Sinclair, and Barbara Gandek for their con­tributions to the data analysis and Samuel C. Haffer for his suggestions on the manu­script.

REFERENCES

Haffer, S., Bowen, S., Shannon, E., et al.: Assessing Beneficiary Health Outcomes and Disease Management Initiatives in Medicare. Disease Management and Health Outcomes 11(2):111-124, February 2003. Jencks, S., Huff, E., and Cuerdon, D.: Change in the Quality of Care Delivered to Medicare Beneficiaries, 1998-1999 to 2000-2001. Journal of American Medical Association 289(3):305-312, January 2003. National Committee for Quality Assurance: HEDIS®2000: Specifications for the Medicare Health Outcomes Survey. National Committee for Quality Assurance. Washington, DC. 2000.

Reprint Requests: Arlene S. Bierman, M.D., M.S., University of Toronto, Inner City Health Research Unit, St. Michael’s Hospital, 30 Bond Street (70 Richmond Street East, 4th Floor) Toronto, Ontario, Canada M5B 1W8. E-mail: arlene.bierman@utoronto.ca

HEALTH CARE FINANCING REVIEW/Summer 2004/Volume 25, Number 4 117