Can Hospitalization-Associated Disability Be Prevented?

Each year, nearly 1 million older adults are hospitalized in the United States for treatment of an acute illness. Although many hospitalizations are necessary and lead to improvement, iatrogenic complications are common. All too frequently, older patients develop infections, pressure ulcers, delirium, adverse effects from treatment, and falls resulting in injury, among other complications. According to a report by the Office of the Inspector General, 7.4% of Medicare beneficiaries who were hospitalized in 2008 experienced a preventable adverse event.¹ To improve the quality and safety of hospital care, Congress has enacted several broad programs that mandate reporting of quality, safety, patient experience, and adverse events and that provide financial incentives to improve performance.

An insidious and underappreciated complication associated with hospitalization of older adults for acute illness is the loss of independence that comes from the inability to perform self-care functions. As noted by Covinsky et al² in this issue of JAMA, at least 30% of patients aged 70 years and older and hospitalized with a medical illness are discharged with a new disability that was not present before the onset of illness. Hospitalization-associated disability involves the new loss of ability, by discharge, to perform at least 1 of the basic activities of daily living (ADLs), such as bathing or showering, dressing, transferring out of a bed or chair, eating, and walking without assistance. The loss of independence has profound implications for these patients often, portending long-term care in a nursing home, repeat hospitalization, and even death.^{2 - 3} Despite the importance of hospitalization-associated disability, it is virtually ignored by health care professionals and policy makers.

One reason for this lack of awareness is that health-related quality of life and sustainability of independence are not measured as outcomes of care. The Centers for Medicare & Medicaid Services (CMS) publishes hospital quality measures on its Hospital Compare Web site, but neither the current nor proposed hospital quality metrics measure health-related quality of life. Starting in October 2012, Medicare will reward hospitals that provide this sort of high-quality care for their patients and withhold a portion of payments to those hospitals that do not through the hospital Value-Based Purchasing (VBP) program. Inpatient, prospective payment hospitals will contribute 1% of their Medicare base operating diagnosis related group payments to a VBP pool of dollars.⁴ Hospitals will be eligible to receive a VBP payment amount based on a composite quality score. Initially, that score will comprise a hospital's performance in process measures and the patient's experience in the hospital. The amount of money at risk increases in succeeding years, and the list of measures will expand to include adverse events, efficiency, and mortality, but no measures of physical function or other aspects of health-related quality of life. Thus, the VBP program will not fully measure and reward value from the patient's standpoint. Most hospitals will focus time and energy only on improving those measures that are publically reported and that determine reimbursement.

Physical function and other dimensions of quality of life should be measured over the course of illness. Simple, valid, and reliable instruments that measure functional status should be incorporated into the care process for older patients and also should be used at regular intervals and at transitions of care.⁵ The value of measurement will increase as hospitals and physicians implement electronic health records, facilitating assessment of health-related quality of life aggregated across populations of older patients to better understand trajectories and causes of physical disability. Measurement alone is not sufficient to address the problem, but measurement would facilitate assessing interventions for effectiveness.

What can and should be done to avert the onset of new disability associated with an acute illness requiring hospitalization? The answer to this question remains unclear and additional study is needed. Although patients at high risk of disability can be identified prospectively,⁶ which patients have reversible and/or preventable loss of function cannot be predicted accurately. The associated disability that occurs during an illness requiring hospitalization may be part of the expected morbidity due to the cumulative burden of aging, frailty, and illness. The additive risk factors for the development of hospital-associated disability are advanced age, existing dependence in ADLs, physical frailty, cognitive impairment, low albumin level, and acute stroke or metastatic cancer,^{3 ,6} suggesting an element of irreversibility.

On the other hand, the hospital environment may contribute to physical disability in some patients. Prolonged bed rest, inadequate nutritional support and overly restrictive diets, overuse of monitors, urinary catheters, intravenous lines that tether patients, and the use of sedating medications all may contribute to loss of function.² Patients should be encouraged to ambulate, with sufficient supervision to avoid increasing fall risk. Good clinical practice dictates that all of these adverse environmental factors can be avoided in older patients. Two basic steps that clinicians could take to help prevent hospital-associated disability are to assess ADLs in all older patients at admission and during hospitalization and to consider how certain interventions may affect a patient's ability to perform ADLs. These basic considerations could help focus care on this important measure, as well as more adequately plan for the discharge transition.

Several interventions have been tested to prevent development of disability in the hospital. Although consultative multidisciplinary assessment teams with geriatric expertise do not improve outcomes, self-contained acute geriatric units have shown modest effects in reducing hospital-associated disability in medical patients and increasing the proportion of patients being discharged to home.^{2 ,7} However, concerns about scalability, the increased costs of operating these units, and the lack of expertise needed to run them have prevented their expansion.

Hospitals should create collaboratives to share knowledge and test interventions designed to determine for which patients physical disability is preventable and treatable. In 2007, the Massachusetts Hospital Association and the Massachusetts Organization of Nurse Executives organized hospitals throughout the state in a voluntary program to report and ultimately to reduce hospital-acquired pressure ulcers, patient falls, and falls with injury.⁸ The data have been used as a foundation for collaborative efforts among the state's hospitals to implement improvement programs and share best practices. As a result of these efforts, statewide prevalence of pressure ulcers decreased nearly 36% from 2007 to 2009. In contrast, neither the rates of hospital falls nor falls with injuries changed. This voluntary hospital effort has 2 important lessons. First, hospitals can and will work together to improve quality of care beyond what is required from a regulatory standpoint. Second, not all quality efforts will be successful even with a strong commitment to succeed. Falls in the hospital, which are often associated with injury, remain a difficult and unsolved problem, and effective interventions to prevent them have only recently been reported.⁹ Reporting and financial incentives alone are insufficient for improvement. Health care professionals need the necessary knowledge and skills to implement interventions and measure outcomes.

In summary, the new onset of disability as part of hospitalization is common and has a major effect on the quality of life and independence of older patients and health-related expenditures. Moreover, the first step to increasing the number of older patients who leave the hospital independent rather than disabled is to systematically measure health-related quality of life and disability outcomes and to report the results publicly. Next, hospitals and health systems should voluntarily work together to test improvement programs and share best practices and outcomes of interventions. Eventually, performance on health-related quality of life should be included as performance metrics in the Medicare VBP program and the proposed bundled payment and shared savings programs. Only through these efforts will preserving and improving patients' independence during hospital stays become a national health care priority.