Venue: The Fuqua School of Business, Duke University, 1 Towerview Drive, Durham, NC 27708-0120
Presentation
Substance Abuse in Nursing Homes: Implications for Cost of Care
OBJECTIVE Substance abuse and dependence, usually considered problems of the young, represent a hidden epidemic among older veterans. The long-term impact on cost of care is uncertain: patients with substance abuse disorders (SUDs) are sicker than average and have fewer home resources, but they also experience higher mortality rates. This study uses a large national sample of U.S. Department of Veterans Affairs (VA) nursing home patients to determine how presence of a substance use disorder affects the use and cost of care over a four-year period.
DATA Data came from VA utilization and cost databases. The sample consisted of persons age 45+ starting a VA nursing home stay in federal fiscal year 2000 (FY2000; 10/01/1999 - 09/30/2000). After data cleaning 30,001 cases remained. Just over 20% (6,429) were identified as having a SUD on the basis of diagnosis codes, procedure codes, and locations of care for VA services during FY1998-FY1999. Data extracted included types and cost of care at VA facilities nationwide plus VA-funded care provided outside VA.
METHOD We developed descriptive statistics on demographics, diagnoses, care patterns, and cost of care. To improve comparability we developed adjusted cost figures for SUD patients using non-SUD patients' distribution of age (5 categories), race (White vs. other), gender, and marital status.
PRINCIPAL FINDINGS SUD patients were more than 50% more likely to have serious mental illnesses such as depression and posttraumatic stress disorder (PTSD), and they were three times more likely to smoke. Each of these is associated with greater health care costs independent of SUD status. SUD patients were also more likely to have HIV/AIDS, but they were less likely to have diabetes or heart disease, most likely due to younger average age.
After 48 months 34% of the cohort was still alive and 2% had never been discharged from the index nursing home stay. Mean nursing home (NH) costs were 29% greater for non-SUD patients while other inpatient costs were similar. After adjusting for age, race, gender, and marital status, the SUD patients had similar NH costs but significantly greater other inpatient costs. Outpatient costs varied between groups but were small relative to inpatient costs.
IMPLICATIONS FOR POLICY, PRACTICE, OR DELIVERY SUDs are relatively common among residents of VA nursing homes and VA-paid community nursing homes. The lower marriage rates among people with SUDs contributes to earlier nursing home placement, thereby increasing public expenditures because such care is often provided through VA or Medicaid. Tailoring SUD treatment programs to middle-aged adults could be cost-effective if it leads to delays in nursing home placement and less expensive care after placement. A second implication concerns smoking. VA and NIH are currently funding clinical tests of smoking cessation programs for people with SUDs. Given the high smoking rate among their residents, it may be cost-effective for NH providers to offer smoking cessation as part of regular nursing home care.