The impact of aging and chronic disease on use of hospital and outpatient services in a large HMO: 1971-1991

OBJECTIVES: To examine overall and diagnosis-specific trends in the use of inpatient and outpatient medical services (1970-1988) among older members of a large HMO. DESIGN: Two cohorts of approximately 3000 persons aged 65 or older in 1971 and 1980 were compared for hospital and outpatient utilization during 9-year follow-up periods (1971-79 and 1980-88). All subjects were evaluated for vital status throughout the follow up period as well. PARTICIPANTS: All 6057 subjects were members of the Northern California Kaiser Permanente Medical Care Program in 1971 or 1980. The study sample was sex-age stratified (65-69,70-79,80+) at baseline. MEASUREMENTS: Data on demographics, outpatient health services utilization, categories of outpatient utilization and disease diagnoses were obtained from membership lists or medical chart review; inpatient utilization, including admitting and discharge diagnosis, length of stay, and number of hospital days was assessed from computerized hospitalization records. RESULTS: Hospital discharge rates (sex-age adjusted) increased by 12% between cohorts, with the largest increases at b the oldest ages. There was a 25% increase among women and a 9% increase among men. Length of stay decreased by 20%. Hospitalization for ischemic heart disease decreased by 17%. Congestive heart failure (CHF) discharge rates (sex-age adjusted) were 92% higher in the 1980-88 cohort. For diagnoses related to nursing home institutionalization and frailty, discharge rates were significantly higher in the 1980-88 cohort: pneumonia (+34%), urinary tract infections (+104%), dehydration (+110%), osteoarthritis (+64%), syncope (+246%), leg cellulitis (+70%). in-hospital survival improved, but overall percent of readmissions also increased by 4%; readmissions for CHF increased by 13% and those for conditions of frailty by 120%. Overall outpatient visits increased by 17%. Use of laboratory tests (+57%) and outpatient surgeries (+99%) increased for all age strata in 1980-88 compared with 1971-79. CONCLUSIONS: While overall outpatient and inpatient utilization has largely decreased over the past 30 years, as a result of economic factors and improved treatments for some major diseases, there has been an increase in utilization among older people. Hospitalization for diagnoses associated with end-stage cardiovascular disease (CHF), musculoskeletal disease, frailty and iatrogenic aspects of institutionalization are clearly increasing substantially. The largest impact of aging on health care may be the result of institutionalization and its sequelae. Improved treatment for cardiovascular disease may also be leading to increased utilization at later stages in the disease process.