The Effect of Short, Unplanned Hospitalizations on Older Adult Functional Status

The functional decline of older adults over acute care hospital stays has been well studied,1 showing that older adults become less mobile and able to care for themselves. However, these studies generally exclude individuals who are admitted to the hospital for fewer than 3 days. Meanwhile, as medical protocols and insurers encourage ever-shorter hospitalizations to reduce costs and iatrogenic illness, the average length of hospitalization for patients aged 65 and older decreased from 10.7 days in 1980 to 5.6 in 2007.2 One-day stays made up 10.3% of Medicare inpatient days during 2013,3 up from 6.8% in 1990.4 A strong understanding of these short stays is becoming increasingly important given Medicare's new two-midnight rule, which will presumptively classify many short stays as outpatient observation. It will be critical to understand how these individuals are affected as hospitals learn to manage their care as outpatients. Seventy-five adults aged 65 and older were interviewed an average of 22.8 days after discharge from 1- to 2-day unplanned hospitalizations at Mount Sinai Hospital. Two hundred eighty-two individuals met the inclusion criteria, 27% of whom were interviewed. It was not possible to interview 16% of potential subjects who spoke Spanish only and 30% who could not be reached after three attempts. Ten percent declined to enroll in the study. Potential subjects were administered the oral components of the Mini-Mental State Examination; the interview was conducted if the individuals scored at least 13 of 19 points. Subjects were asked about their ability to perform 11 activities of daily living (ADLs) based on the Duke Activity Status Index (DASI),5 which assigns a weighted number of points to each activity according to its difficulty. Subjects were given two aggregate scores based on their ability to perform the ADLs before hospitalization and at the time of interview. Subjects were also asked whether they required the help of family, friends, or professional aides for care at the same two time points. Interviewed individuals were on average 76.9 years old; 57% were male, 48% were white, and 20% black, similar to all individuals who met the inclusion criteria. The Case Mix Index (CMI), the average of a group of diagnosis-related group weights and a measure of disease severity and expected resource use, was 0.96 for the 75 interviewed individuals, compared to 2.01 for all Mount Sinai Hospital Medicare patients during the study period. Major results are presented in Table 1. Subjects had an average change in ADL score of −19.3%. Decline correlated strongly with increases in need for help from family, friends, and professional aides, and needing help before admission was strongly correlated with very low (11.2) ADL scores after discharge. Decline did not correlate with age. Participants who stayed for 2 days declined significantly less between admission and interview than those who stayed for 1 day, despite no statistically significant difference in CMI (0.93 and 0.98, respectively; P = .61). Even after short stays in the hospital, older adults experience decline that can be substantial. This may inform discharge planning given that Medicare guidelines prevent coverage of postacute skilled care for any hospital stay that is shorter than 3 days. Therefore, individuals who meet the inclusion criteria of this study must be discharged to home with only the limited Medicare home healthcare benefit. Furthermore, as Medicare's two-midnight rule takes effect, hospitals and clinicians must recognize that even individuals presumptively classified as hospital outpatients receiving observation services may experience adverse effects of hospitalization, despite their outpatient status. This study showed what clinicians and discharge planners know intuitively; ADL decline corresponds with greater caregiving load on family, friends, and professional aides of older adults. It also showed that a detailed history of the preadmission caregiving needs of an individual can help clinicians predict how their patients will fare weeks after discharge, as prior need for help strongly implies that the individual will experience significant functional decline and will have a low ADL score after being sent home. Interestingly, participants who stayed for 1 day as opposed to 2 experienced greater decline despite having a similar CMI. Further research is needed to determine whether these are two different groups of individuals admitted for different reasons and types of care or whether individuals with similar reasons for hospitalization receive a functional benefit from remaining a second day in the hospital. Limitations included small sample size, study in a single institution, lack of verification of self-reported ADL capacity, and interview of only 27% of individuals meeting inclusion criteria. The authors would like to thank Dr. Albert Siu for his expert guidance and Doran Ricks for providing assistance with the administrative claims data. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. This research was funded by the Medical Student Training in Aging Research Program Administered by the American Federation for Aging Research and the National Institute on Aging. Author's Contributions: Oakland H.T.: conception and design, acquisition of data, analysis and interpretation of data, drafting of the article, final approval of the article to be published. Farber J. I.: conception and design, acquisition of data, analysis and interpretation of data, critical revision of the article, final approval of the article to be published. Sponsor's Role: The sponsors were not involved in the design, methods, subject recruitment, data collections, analysis, or preparation of this paper.