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What’s New in the Patient Safety World

October 2019

Visual and Hearing Loss and Medical Costs

 

 

We’ve done several columns on the impact of hearing loss on healthcare costs. But, what about visual loss? We have noted how issues related to vision loss may impact risk for falls and delirium.

 

Morse et al. (Morse 2019) used 2 large databases of healthcare claims to compare costs incurred following an initial hospitalization for common illnesses by patients with partial visual loss (PVL) or severe visual loss (SVL) vs. those who had no visual loss (NVL).

 

Medicare enrollees with SVL, compared with those with NVL, had longer mean lengths of stay (6.48 vs 5.26 days), higher readmission rates (23.1% vs 18.7%), and higher hospitalization and 90-day postdischarge costs ($64,711 vs $61,060). That translates to a 4% longer LOS, 22% higher odds of readmission, and 12% higher costs. Similar findings were obtained for those with commercial health insurance.

 

Extrapolating, they estimated more than $500 million in additional costs annually were spent caring for these patients.

 

Health Leaders recently highlighted programs at Johns Hopkins and Miami’s Bascom Palmer Eye Institute to engage visually impaired patients and their families during hospitalizations (Cheney 2019). The three areas of focus are patient safety, special accommodations, and discharge and medication management.

 

Patient safety considerations include braille on the call button, and special guardrails in the stairwells that extend beyond the end of the staircase. In addition, at Hopkins a staff member with them when they are getting up for the first time after surgery and when they are walking the hallways. Physical therapists and techs also ask the patient “How would you like me to best lead you?”

 

Special accommodations include special signage with high-contrast colors, consistent lighting, and door signage in braille. Johns Hopkins is implementing a Bluetooth way-finding app that can be used from home or while using public transportation. It has voice capability and helps navigate the patient through the hospital, including such things as telling them when to enter an elevator, what button to push, and what floor they are on. At both Hopkins and Bascom Palmer, staff get special training to deal with vision-impaired patients.

 

Discharge and medication instructions are critically important. Use of audio-recorded instructions is helpful and any written materials use large font sizes or formats that can be used with a screen reader. Medication packaging may have braille or larger print.

 

It has become increasingly important that we recognize sensory impairments in all patients, not just the elderly, in all healthcare venues. We need to take special precautions to ensure we communicate appropriately with those patients and make their ability to navigate the system as error-free as possible.

 

A recent study (Reed 2019) followed 4,728 people, half of whom had untreated hearing loss, for a decade starting when they were 61 years old, on average. Untreated hearing loss was associated with $22 434 or 46% higher total health care costs over a 10-year period compared with costs for those without hearing loss. Persons with untreated hearing loss had more inpatient stays (incidence rate ratio, 1.47) and were at greater risk for 30-day hospital readmission (relative risk, 1.44) at 10 years. Similar trends were observed at 2- and 5-year time points across measures.

 

Another study (Deal 2019) compared patients aged 50 and older who had claims for hearing loss to a propensity matched cohort. Those with hearing loss had a 50% higher risk of dementia and 41% increased risk of depression at 5 years of follow up. The 10-year risk attributable to hearing loss was 3.20 per 100 persons for dementia, 3.57 per 100 persons for falls, and 6.88 per 100 persons for depression.

 

In several of our columns listed below, we have made a case that hearing loss is a patient safety issue and that use of hearing aids is underutilized. Now a new study (Mahmoudi 2019) found that use of hearing aids in patients aged 66 and older with hearing impairment is associated with a longer time to diagnosis of Alzheimer disease, dementia, depression, anxiety, and injurious falls. Just having an association does not prove causality and it’s probably unlikely that a randomized controlled trial will be done, but it makes sense that improved hearing via hearing aids could lead to the improvements noted.

 

And, for years, those of us who are neurologists have recognized the “multiple sensory deficit” syndrome as a major cause of impaired ambulation and falls. Many older patients have impairments of sensory function (such as vision, hearing, vestibular function, and proprioception) that individually are not severe enough to produce disability but collectively have an additive or synergistic effect that does result in disability. In our February 2018 What's New in the Patient Safety World column “Global Sensory Impairment and Patient Safety” we noted that geriatricians have now begun to take a broader look at a related concept, “global sensory impairment” (GSI), and its impact on overall health. Patients with worse GSI scores were more likely to have poorer overall health and lose weight, and have died in a 5-year follow up study (Pinto 2017).

 

It's quite likely that interventions which improve at least vision and hearing may be effective patient safety interventions that reduce overall costs in the health system. Currently, Medicare (other than Medicare Advantage plans) does not cover either glasses or hearing aids. Studies like those above are important in suggesting a likely net benefit from such programs. However, we also need to keep in mind that sometimes there are unintended consequences. For example, several of our prior columns have noted paradoxical increases in falls after certain types of vision correction.

 

 

Some of our previous columns on falls after correction of vision:

 

June 2010        “Seeing Clearly a Common Sense Intervention

June 2014        “New Glasses and Fall Risk

August 2014   “Cataract Surgery and Falls

 

 

Some of our columns on the impact of hearing loss:

September 12, 2017 “Can You Hear Me Now?

February 2018 “Global Sensory Impairment and Patient Safety

July 2018 “Hearing Loss and Patient Safety

November 2018 “More on Hearing Loss

 

 

 

References:

 

 

Morse AR, Seiple W, Talwar N, Lee PP, Stein JD. Association of Vision Loss With Hospital Use and Costs Among Older Adults. JAMA Ophthalmol 2019; 137(6): 634-640 Published online April 04, 2019

https://jamanetwork.com/journals/jamaophthalmology/article-abstract/2729901

 

 

Cheney C. Focus on 3 Areas When Caring for Vision-Impaired Hospital Patients. Health Leaders 2019; August 21, 2019

https://www.healthleadersmedia.com/clinical-care/focus-3-areas-when-caring-vision-impaired-hospital-patients

 

 

Reed NS, Altan A, Deal JA, et al. Trends in Health Care Costs and Utilization Associated With Untreated Hearing Loss Over 10 Years. JAMA Otolaryngol Head Neck Surg 2019; 145(1): 27-34

https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2714049

 

 

Deal JA, Reed NS, Kravetz AD, et al. Incident Hearing Loss and Comorbidity: A Longitudinal Administrative Claims Study. JAMA Otolaryngol Head Neck Surg 2019; 145(1): 36-43

https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2714050

 

 

Mahmoudi, E. , Basu, T. , Langa, K. , McKee, M. M., Zazove, P. , Alexander, N. and Kamdar, N. (2019), Can Hearing Aids Delay Time to Diagnosis of Dementia, Depression, or Falls in Older Adults?. J Am Geriatr Soc. 2019; First published September 4, 2019

https://onlinelibrary.wiley.com/doi/10.1111/jgs.16109

 

 

Pinto JM, Wroblewski KE, Huisingh-Scheetz M, et al. Global Sensory Impairment Predicts Morbidity and Mortality in Older U.S. Adults. J Am Geriatr Soc 2017; 65: 2587-2595

http://onlinelibrary.wiley.com/doi/10.1111/jgs.15031/full

 

 

 

 

 

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