Abstract
Differences in utilization patterns for patients with IDD provide a basis for occupational therapy practitioners to be leaders in adapting treatment protocols and providing education to caregivers and health care providers.
In the United States, approximately 7.3 million Americans have intellectual and developmental disabilities (IDD; Anderson et al., 2019), which are defined as limitations in mental functioning or adaptive behavior with a developmental onset (American Association on Intellectual and Developmental Disabilities, 2020). Both the life expectancy and the number of people with IDD has increased in the past decade (Dolan et al., 2019), and the population with IDD has become increasingly susceptible to age-related illnesses such as osteoporosis (Dolan et al., 2019), dementia (Coppus, 2013), and Type 2 diabetes (Taggart et al., 2018). These risk factors, along with common comorbidities such as obesity, epilepsy, and cardiovascular disease, heighten the risk of falls and associated traumatic injuries at a younger age (Cox et al., 2010), leading to surgical replacement procedures (Hamel et al., 2008). Other studies have found that people with IDD have more complex care needs and often experience postsurgical complications (Ailey et al., 2015). Consequently, emergency rooms and acute care hospitals have witnessed an increase in the number of people with IDD seeking treatment (Glover et al., 2019).
Research has suggested that health care providers in hospital settings lack the knowledge, skills, and attitudes required to serve the unique needs of people with IDD (Morin et al., 2018; Selick et al., 2018); inadequate preparation (Williamson et al., 2017) and inability to effectively communicate are the primary causes for concern (Appelgren et al., 2018). Nurses have self-reported feeling unprepared to meet the needs of people with IDD and the belief that this affects the ability of the health care system to serve people with IDD (Appelgren et al., 2018). Given the high prevalence of comorbidities among the population with IDD, these patients may experience increased complexity of care and require additional medical treatment or resources. Despite this complexity, considerable risk of injury, and increased prevalence in health care facilities, no codified national standard or protocol currently exists for medical treatment of the population with IDD within the United States (Ervin et al., 2014). Enhancing knowledge and skills to establish effective therapeutic relationships may assist in meeting the needs of this population (Appelgren et al., 2018).
Occupational therapy practitioners are an important component of the interprofessional team in acute care settings. Occupational therapy addresses people’s participation in activities of daily living (ADLs) and instrumental ADLs that facilitate safe return to home after an injury or illness and prevent hospital readmission (Rogers et al., 2016). Occupational therapy practitioners are able to address the needs of people with IDD, but general health care settings may not be as tailored to those needs as facilities specifically for patients with IDD.
The research literature on hospital care for people with IDD is limited, with a majority of published studies focusing on hospital length of stay (LOS). These studies have found that people with IDD experience longer LOS (Ailey et al., 2019); however, they did not focus on the specific conditions among people with IDD that led to hospitalization. Therefore, the purpose of this study was to describe the population of adults with IDD in hospital settings and identify differences in their health care utilization patterns compared with adults without IDD. By describing patterns in LOS, frequency of occupational therapy treatment, insurance coverage, and discharge environment, we aim to provide generalized insight into the care of adults with IDD to create a foundation for future research to address the needs of this population and to expand and codify a national treatment standard in the United States (Ervin et al., 2014).
Method
Design
This was a retrospective exploratory study with a cross-sectional design. We conducted descriptive and comparative analyses of hospital discharge data for patients with and without IDD who were admitted to the hospital for an orthopedic procedure between January 2017 and December 2018.
Participants
We obtained data from Clinical Data Base/Resource Manager™ (Vizient, Irving, TX), a database of discharge abstracts from academic medical centers, their affiliated hospitals, and other community hospitals in the United States. Our primary institution is a member of the Vizient network, thus providing us access to the database.
Data were extracted for adults (ages ≥18 yr) discharged between January 2017 and December 2018 who received a lower extremity orthopedic procedure (n = 603,546), as identified by 1 of 44 Diagnosis Related Group (DRG) codes (Centers for Medicare & Medicaid Services, 2020; Appendix A). The decision to examine orthopedic conditions was driven by the high prevalence of falls in the population with IDD, which may result in orthopedic injury and hospitalization (Cox et al., 2010). A subsample of all patients with IDD (n = 2,118) was identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes (World Health Organization, 1992; Appendix B). Persons were identified as having IDD if any of the diagnoses listed in Appendix B was ever present in their discharge abstracts in the Vizient database. An age- and gender-matched control cohort sample (1:3) of patients without IDD (n = 6,354) was identified using stochastic matching for comparative analysis (Rässler, 2002).
Procedure
Approval from Rush University’s institutional review board was obtained (Office of Research Affairs No. 19032703). To ensure objectivity and decrease bias in data selection, the matched samples were created by generating random numbers for all patients without IDD and then selecting the matching control patients with the highest random numbers. The final selected database was then used for the analyses described in this article. Demographic, insurance, and discharge information was obtained for these patients. Data were divided into four age bands: 18–30 yr, 31–50 yr, 51–70 yr, and >70 yr. Orthopedic DRG codes were grouped into categories of similar codes for analysis (see Appendix A). Occupational therapy procedures were identified by matching charge codes to occupational therapy Current Procedural Terminology (CPT ® ; American Medical Association, 2020) codes.
Data Analysis
Analysis was conducted using IBM SPSS Statistics (Version 25.0; IBM Corp., Armonk, NY). Descriptive statistics were performed for both the study cohort and the matched control group. Independent t tests and χ2 analyses were conducted to identify differences between the samples.
Results
Adults with IDD represented 0.35% of the 603,546 encounters in the database. The most common IDD diagnosis was unspecified intellectual disability (n = 1,551). The top three orthopedic procedures were the same for both groups—hip or knee replacement, spinal fusion, and lower extremity or humerus procedure—although they were distributed differently between the two samples (Table 1). In the IDD sample, almost half (45.9%) of the admissions for orthopedic procedures occurred among people ages 50–70 yr, and admissions occurred in all adult age group bands.
Descriptive Statistics of Sample Populations
Note. — = not applicable; IDD = intellectual and developmental disabilities; LE = lower extremity.
Within the IDD sample of 2,118 participants, there were a total of 3,722 IDD diagnoses, suggesting participants had multiple classifications of IDD.
The clinical profiles of the two groups differed significantly. The mean LOS for people with IDD (M = 6.51, SD = 7.77) was significantly longer than for those without IDD (M = 3.89, SD = 5.37), t(2821.5) = −14.2, p < .001. The proportion of both samples who received occupational therapy services was nearly identical, χ2(1, N = 7,187) = 0.352. Of those who received occupational therapy services, participants with IDD received more days of occupational therapy than those without IDD (Table 2). Significant differences in insurance providers were noted; the majority of participants with IDD had Medicare (65.7%), whereas the majority of participants without IDD had private insurance (41.5%). Significant differences were also noted in discharge placements. A little more than half of the participants with IDD were discharged to 24-hr care settings (rehabilitation, subacute, or skilled nursing facilities [SNFs]), whereas the most common discharge placement for participants without IDD was home with or without home health services (Table 3).
Results of t Test Examining Receipt of Occupational Therapy Services
Note. IDD = intellectual and developmental disabilities; OT = occupational therapy.
Of the two samples, 85.5% (n = 1,810/2,118) of the IDD sample and 84.6% (n = 5,377/6,354) of the non-IDD sample received OT services.
p < .001.
Distribution of Insurance Provider and Discharge Environment
Note. Percentages may not total 100 as a result of rounding. IDD = intellectual or developmental disabilities; SNF = skilled nursing facility.
IDD sample, n = 2,118; non-IDD sample, n = 6,354. bIDD sample, n = 2,118; non-IDD sample, n = 6,339.
p < .001.
Discussion
This study compared age- and gender-matched samples of adults with and without IDD who were admitted to acute care hospitals for an orthopedic procedure. The results show that both groups appear to have been hospitalized for the same top three orthopedic procedures, suggesting that adults with and without IDD experience similar orthopedic conditions, and they affirm previous research indicating that people with IDD and the general population experience similar age-related health conditions. As stated earlier, age-related osteopathies often lead to falls or surgical replacement procedures (Hamel et al., 2008), such as hip or knee replacements, which were the top orthopedic procedures for the IDD sample. Therefore, the results of this study and previous literature suggest that preventive services tailored to adults with IDD, including fall prevention programs, are warranted.
We found no significant difference between the two samples in the initiation of occupational therapy procedures; a similar percentage of each sample received occupational therapy procedures during their stay. However, there was a significant difference in the number of occupational therapy procedures provided in total. This difference in total procedures is because participants with IDD had longer LOS, resulting in occupational therapy procedures delivered on more days. Despite the higher total number of occupational therapy procedures among the IDD sample, the number of procedures provided to the IDD sample was not proportionate to the longer LOS. Participants with IDD experienced nearly double the LOS, but the total number of occupational therapy procedures did not double accordingly. This difference could be attributed to several factors, including potential refusal of treatment, increased complexity of care, or insurance coverage (Hernandez et al., 2015) for the population with IDD. Future research could explore the reasons why occupational therapy service dosing is not directly proportional to LOS and identify whether the dosing differences are appropriate.
Despite the two samples experiencing similar orthopedic conditions and being age matched, participants with IDD were more often discharged to a SNF than were those in the sample without IDD, who were primarily discharged home. Patients discharged to a SNF are typically older or have comorbid conditions that require more support for ADLs (Britton et al., 2017). Similarly, people with IDD often have a higher rate of comorbid conditions or postsurgical complications that may warrant discharge to a SNF.
The results also showed that the majority of participants with IDD had Medicare. The combination of IDD and having Medicare may result in providers being more cautious and implementing longer observation periods or discharge to a SNF, where patients continue to receive 24-hr care to avoid rehospitalization. For a Medicare recipient’s stay at a SNF to be covered by Medicare Parts A and B, however, the patient must first spend 3 full consecutive days in an acute care or hospital setting before transfer (Hernandez et al., 2015). This requirement may also influence the LOS for adults with IDD who are discharged to SNFs.
This study indicates that people with IDD who receive hospital-based orthopedic procedures are interacting in a variety of health care settings. Provider bias, as well as communication challenges between providers and patients, may affect quality of care and lead to longer LOS for patients with IDD. Education on how to effectively and respectfully interact with and treat patients with IDD could influence the care of this population. It is also important for providers to establish effective communication with caregivers, because almost half of the participants with IDD in this study were discharged directly home. Implementation of caregiver education on postoperative care, fall risk prevention, and signs of age-related illnesses could significantly reduce the risk of injury or need for rehospitalization.
Limitations
Data were generated exclusively from the Vizient database; thus, the sample is not nationally representative. In addition, the data rely on accurate coding for IDD diagnoses, which may not have been the case.
Implications for Occupational Therapy Practice
Occupational therapy practitioners can contribute to improving health outcomes for adults with IDD by
Being prepared to address learning differences among adults with IDD along with recovery from orthopedic procedures in all health care settings.
Designing and providing fall prevention protocols specific to people with IDD.
Including caregiver education about postoperative care, fall risk prevention, and signs of age-related illness in treatment protocols for adults with IDD.
Addressing communication barriers faced by people with IDD in hospital settings by advocating for their needs and educating other health care providers on effective communication and treatment practices.
Collaborating with members of the interprofessional team to identify and recognize varying viewpoints in the care of people with IDD, including that of the patient, to ensure that appropriate intervention and discharge recommendations are being made.
Recommendations for Future Research
Future research should examine other specialty service lines frequently used by adults with IDD, such as neurology and cardiology, as well as other rehabilitative services typically associated with acute care stays to gain a comprehensive view of health care utilization in this group and provide guidance for education and treatment protocols. In addition, a small number of hospitals provide programming and recommendations specific to people with IDD; examining the clinical outcomes of these programs could yield valuable information about improving care. Future research could also include admission rates of adults to SNFs to determine whether diagnosis of an IDD has an identifiable impact on discharge planning without confounding variables such as orthopedic complications or insurance reimbursement and whether a SNF is the most appropriate environment for aging patients with IDD. Finally, future studies could identify whether intervention protocols designed specifically for patients with IDD and their caregivers affect the effectiveness of care in an acute care setting.
Conclusion
This study aimed to compare hospital utilization patterns of orthopedic patients with and without IDD to provide insight on differences between them. Adults with IDD in acute care hospital settings for lower extremity orthopedic procedures experience longer LOS and different patterns of occupational therapy use and discharge placement. This variation in health care may be attributed to increased complexity of care, presence of comorbid conditions, Medicare reimbursement requirements, and unpreparedness of medical staff. Despite variations in occupational therapy use, occupational therapy services were similar for the two populations, indicating that occupational therapy is provided regardless of an IDD diagnosis.
This study presents novel information describing adults with IDD in acute care hospitals and serves as a call to action for occupational therapy practitioners to be leaders in adapting treatment and prevention protocols for the population and to provide education to caregivers and health care providers about effective communication. By implementing such practices, occupational therapy practitioners can develop a national treatment standard for working with people with IDD in health care facilities and encourage equitable care for this underserved population.
Footnotes
Acknowledgments
We thank Sam Hohmann and Alyssa Harris of Vizient, Inc., for providing data and methodological guidance.