Introduction
Falls are risky for older adults, leading to hospitalizations and long-term care.1 Autistic older adults may have increased fall risk due to motor coordination2 or executive function3 difficulties. However, we know little about fall-related hospitalization care and outcomes among this population. We compared matched samples of autistic and non-autistic older adults with fall-related hospitalizations on length of stay (LOS), receipt of inpatient occupational therapy (OT) or physical therapy (PT), discharge destination, and 30-day readmission, with analyses stratified by age. We hypothesized autistic older adults had longer LOS, were less likely to receive OT or PT, less likely to be discharged home, and greater risk of readmission than non-autistic older adults, regardless of age.
Methods
This cross-sectional retrospective cohort study analyzed 100% inpatient Medicare claims from 2013–2021 Standard Analytical Files. Autistic older adults were: aged ≥65 years; enrolled in Medicare Parts A and B for ≥12 months consecutively; hospitalized for a fall for ≥ one night; and identified with an autism diagnosis in ≥ one inpatient or outpatient encounter. We identified fall-related hospitalizations using International Classification of Disease (ICD) codes E880-E888.9 from the 9th edition or W00-W19 from the 10th edition. We excluded Medicare Advantage beneficiaries. A sample of non-autistic older adults was propensity score matched (1:1) with autistic older adults on sex, race, age, hospitalization year, Charlson Comorbidity Index (CCI),4 and longitude/latitude coordinates of county residence. Dependent variables, obtained from the first observed fall-related hospitalization, included: LOS; receipt of OT; receipt of PT; discharge home; discharge to skilled nursing facility (SNF); discharge to inpatient rehabilitation; all-cause 30-day readmission. Covariates included sex, race, age, rurality, region, estimated income, healthcare management organization status, hospitalization year, Charlson Comorbidity Index, U.S. Veterans Affairs Frailty Index,5 history of insomnia, and history of any mental health condition. See Table 1 footnote for variable operationalization. We used multivariable negative binomial regression to compare autistic and non-autistic older adults’ LOS and multivariable log binomial regression to compare OT and PT receipt, discharge destination, and readmission, stratifying all models by age, with a significance level of 0.05. In a sensitivity analysis, we controlled for dual Medicaid eligibility, available only for participants with first fall-related hospitalizations during 2016–2021.
Table 1.
Demographics, clinical characteristics, and outcomes for matched cohort of autistic and non-autistic Medicare beneficiaries
| Non-autistic older adults (n=1,614) |
Autistic older adultsa (n=1,614) |
Total (N=3,228) |
Effect Sizeb | |
|---|---|---|---|---|
| Demographics | ||||
| Age, n(%) | 0.08 | |||
| 65–69 | 996 (61.71%) | 1,041 (64.50%) | 2,037 (63.10%) | |
| 70–74 | 359 (22.24%) | 274 (16.98%) | 633 (19.61%) | |
| 75+ | 259 (16.05%) | 299 (18.53%) | 558 (17.29%) | |
| Male, n (%) | 1,067 (66.11%) | 1,067 (66.11%) | 2,134 (66.11%) | <0.01 |
| Race and Ethnicity, n (%) | <0.01 | |||
| White, non-Hispanic | 1,492 (92.44%) | 1,492 (92.44%) | 2,984 (92.44%) | |
| Black, non-Hispanic | 64 (3.97%) | 64 (3.97%) | 128 (3.97%) | |
| Hispanic | 12 (0.74%) | 12 (0.74%) | 24 (0.74%) | |
| Other | 46 (2.85%) | 46 (2.85%) | 92 (2.85%) | |
| Region, n (%) | 0.08 | |||
| Midwest | 321 (19.89%) | 408 (25.28%) | 729 (22.58%) | |
| Northeast | 472 (29.24%) | 423 (26.21%) | 895 (27.73%) | |
| Other | 313 (19.39%) | 305(18.90%) | 618 (19.14%) | |
| South | 508 (31.47%) | 478 (29.62%) | 986 (30.55%) | |
| Rurality, n (%) | ||||
| Large Metro Area (>1,000,000) | 781 (48.39%) | 811 (50.25%) | 1,592 (49.32%) | 0.13 |
| Small Metro Area (<1,000,000) | 459 (28.44%) | 549 (34.01%) | 1,008 (31.23%) | |
| Metro Area Adjacent | 174 (10.78%) | 163 (10.10%) | 337 (10.44%) | |
| Non-Metro Area (>2,500) | 131 (8.12%) | 70 (4.34%) | 201 (6.23%) | |
| Rural Area (<2,500) | 69 (4.28%) | 21 (1.30%) | 90 (2.79%) | |
| Estimated Household Income,c median (IQR)d | 40.83 (34.92, 48.40) | 41.62 (35.72, 49.14) | 41.11 (35.43, 48.78) | 0.08 |
| Dual Eligible,e n (%) | 119 (11.94%) | 587 (58.88%) | 706 (35.41%) | 0.49 |
| HMOf Status, n (%) | 1,158 (71.75%) | 129 (7.99%) | 1,287 (39.87%) | −0.65 |
| Hospitalization Year, median (IQR) | 2014 (2013, 2016) | 2014 (2013, 2017) | 2014 (2013, 2016) | 0.02 |
| CCI,g median (IQR) | 0 (0, 2) | 0 (0, 2) | 0 (0, 2) | <0.01 |
| VA-Frailty Score,h median (IQR) | 0.19 (0.10, 0.32) | 0.23 (0.13, 0.32) | 0.23 (0.13, 0.32) | 0.14 |
| History of Insomnia,i n (%) | 281 (17.41%) | 306 (18.96%) | 587 (18.18%) | 0.02 |
| History of Any Mental Health Condition,i n (%) | 1,066 (66.05%) | 1,326 (82.16%) | 2,392 (74.10%) | 0.18 |
| Outcomes | ||||
| Length of Stay, median (IQR) | 4 (2, 7) | 4 (3, 7) | 4 (2, 7) | 0.06 |
| Receipt of OT,j n (%) | 734 (45.48%) | 733 (45.42%) | 1,467 (45.45%) | <0.01 |
| Receipt of PT,k n (%) | 1,145 (70.94%) | 1,158 (71.75%) | 2,303 (71.34%) | <0.01 |
| Discharged Home, n (%) | 810 (50.19%) | 495 (30.67%) | 1,305 (40.44%) | −0.20 |
| Discharged to SNF,l n (%) | 455 (28.19%) | 706 (43.74%) | 1,161 (35.97%) | 0.16 |
| Discharged to Inpatient Rehabilitation, n (%) | 125 (7.74%) | 84 (5.20%) | 209 (6.47%) | −0.05 |
| Readmission,m n (%) | 760 (47.09%) | 1,001 (62.02%) | 1,761 (54.55%) | 0.15 |
Autism diagnoses were identified by at least one inpatient or outpatient encounter with ICD-9 codes 299.0x, 299.9x or ICD-10 codes F84.0, F84.1, F84.5, or F84.9;
Effect sizes were calculated as Cohen’s d for continuous variables, Phi coefficient for binary variables and Cramer’s v for categorical variables;
Estimated annual household income is reported in tens of thousands and was estimated based on county, year, and U.S. Census Bureau information;
IQR=Interquartile Range;
Dual Medicaid and Medicare enrollment status was only collected from 2016 through 2021 and thus was only available for participants with first observed fall-related hospitalizations during those years;
HMO=Healthcare Management Organization;
CCI=Charlson Comorbidity Index;
VA-Fraily Score=Veterans Affairs Frailty Score;
History of insomnia and history of any mental health condition prior to first observed fall-related hospitalization were identified using the Healthcare Cost and Utilization Project’s (HCUP) Clinical Classifications Software Refined (CCSR) for ICD-10 and General Equivalence Mapping to identify corresponding ICD-9 codes;
OT=Occupational Therapy, which was identified via revenue center codes 0430–0433, 0439, 0978;
PT=Physical Therapy, which was identified via revenue codes 0420–0423, 0429, 0977;
SNF=Skilled Nursing Facility;
All-cause 30-day inpatient readmission
Results
Table 1 describes sample characteristics. Autistic older adults had longer LOS than non-autistic peers (Table 2). During fall-related hospitalizations, autistic older adults had 11% lower risk of receiving OT, but did not differ in receipt of PT compared to non-autistic peers. Autistic older adults had 38% lower risk of being discharged home and 37% lower risk of being discharged to inpatient rehabilitation than non-autistic peers. Autistic older adults had 65% greater risk of being discharged to a SNF and 18% greater risk of 30-day readmission. Results of age-stratified analyses were largely consistent with overall findings, except some differences between autistic and non-autistic older adults were not statistically significant at older age categories, particularly for LOS, OT, and readmission. Results of the sensitivity analysis controlling for dual Medicaid eligibility were consistent with main analyses.
Table 2.
Multivariable results comparing autistic to non-autistic older adults, controlling for sex, race, rurality, age, year, region, estimated annual household income, HMO status, CCI, history of any mental health condition, history of insomnia, and frailty
| Outcome | Overall | Age 65–69 | Age 70–74 | Age 75+ |
|---|---|---|---|---|
| Length of Stay, IRRa (95% CIb) | 1.09 (1.01, 1.18) | 1.13 (1.04, 1.24) | 1.03 (0.89, 1.20) | 0.97 (0.83, 1.13) |
| Receipt of Occupational Therapy, RRc (95% CI) | 0.89 (0.81, 0.99) | 0.88 (0.79, 0.98) | 0.91 (0.77, 1.08) | 0.93 (0.77, 1.13) |
| Receipt of Physical Therapy, RR (95% CI) | 0.98 (0.93, 1.05) | 0.99 (0.92, 1.06) | 1.01 (0.91, 1.12) | 0.93 (0.84, 1.03) |
| Discharged Home, RR (95% CI) | 0.62 (0.56, 0.68) | 0.63 (0.56, 0.71) | 0.55 (0.44, 0.69) | 0.63 (0.48, 0.81) |
| Discharged to SNF,d RR (95% CI) | 1.65 (1.46, 1.86) | 1.74 (1.51, 2.01) | 1.57 (1.26, 1.95) | 1.48 (1.20, 1.82) |
| Discharged to Inpatient Rehabilitation, RR (95% CI)e | 0.63 (0.44, 0.88) | |||
| Readmission,f RR (95% CI) | 1.18 (1.08, 1.28) | 1.17 (1.06, 1.28) | 1.11 (0.96, 1.29) | 1.25 (1.08, 1.44) |
IRR=Incidence Rate Ratio;
CI=Confidence Interval;
RR=Risk Ratio;
SNF=Skilled Nursing Facility;
Due to the rarity of this outcome, it could not be stratified by age;
All-cause 30-day inpatient readmission
Discussion
We identified potential disparities among autistic older adults hospitalized for falls, including an 18% greater risk of readmission. In the general population, inpatient OT6 and rehabilitation7 are associated with lower readmission for myriad conditions. Yet, autistic older adults in this study had lower receipt of these services than non-autistic peers, despite longer LOS. Findings may suggest a need to increase OT and PT for autistic older adults hospitalized for falls, potentially attenuating readmission risk. Autistic adults’ lower risk of being discharged home and greater risk of being discharged to a SNF may suggest less robust home support systems, or the perception of such by discharging providers, compared to non-autistic peers. Exploring the role of home support may be a viable avenue for reducing readmissions after fall-related hospitalizations. Additionally, clinician assumptions about patients’ ability to participate in care planning may have influenced outcomes. Limitations include a lack of Medicare Part D data, preventing controlling for medication use, and sample racial homogeneity, limiting generalizability. Next steps include examining the impact of surgical intervention and the Coronavirus pandemic on outcomes. Future research should focus on identifying and addressing autistic older adults’ barriers to fall-related care, ultimately aiming to reduce readmission rates and improve wellbeing.
Acknowledgements
Contributors:
Janet E. Childerhose, PhD, Division of General Internal Medicine, The Ohio State University
Funding:
Research reported in this publication was supported by the National Institutes on Aging of the NIH under award No. R01AG082873. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Footnotes
Human Ethics and Consent to Participate declarations: This work was determined to be IRB exempt by The Ohio State University due to the use of limited datasets
Competing Interests declarations: None
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