The optimal outcomes of post-hospital care under medicare.
OBJECTIVE
To estimate the differences in functional outcomes attributable to discharge to one of four different venues for post-hospital care for each of five different types of illness associated with post-hospital care: stroke, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hip procedures, and hip fracture, and to estimate the costs and benefits associated with discharge to the type of care that was estimated to produce the greatest improvement.


METHODS
Consecutive patients with any of the target diagnoses were enrolled from 52 hospitals in three cities. Data sources included interviews with patients or their proxies, medical record reviews, and the Medicare Automated Data Retrieval System.


METHODS
A two-stage regression model looked first at the factors associated with discharge to each type of post-hospital care and then at the outcomes associated with each location. An instrumental variables technique was used to adjust for selection bias. A predictive model was created for each patient to estimate how that person would have fared had she or he been discharged to each type of care. The optimal discharge location was determined as that which produced the greatest improvement in function after adjusting for patients' baseline characteristics. The costs of discharge to the optimal type of care was based on the differences in mean costs for each location.


METHODS
Data were collected from patients or their proxies at discharge from hospital and at three post-discharge follow-up times: six weeks, six months, and one year. In addition, the medical records for each participant were abstracted by trained abstractors, using a modification of the Medisgroups method, and Medicare data were summarized for the years before and after the hospitalization.


RESULTS
In general, patients discharged to nursing homes fared worst and those sent home with home health care or to rehabilitation did best. Because the cost of rehabilitation is high, greater use of home care could result in improved outcomes at modest or no additional cost.


CONCLUSIONS
Better decisions about where to discharge patients could improve the course of many patients. It is possible to save money by making wiser discharge planning decisions. Nursing homes are generally associated with poorer outcomes and higher costs than the other post-hospital care modalities.
Kane
R L
RL
University of Minnesota School of Public Health, Minneapolis 55455, USA.
Chen
Q
Q
Finch
M
M
Blewett
L
L
Burns
R
R
Moskowitz
M
M
D000203:Activities of Daily Living; D000359:Aftercare / Q000191:economics / Q000458:organization & administration*; D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000191:economics / Q000534:rehabilitation; D003362:Cost-Benefit Analysis; D005500:Follow-Up Studies; D006302:Health Services Research / Q000458:organization & administration; D006333:Heart Failure / Q000191:economics / Q000534:rehabilitation; D006620:Hip Fractures / Q000191:economics / Q000534:rehabilitation; D006699:Home Care Services; D006801:Humans; D008173:Lung Diseases, Obstructive / Q000191:economics / Q000534:rehabilitation; D008485:Medical Audit; D006278:Medicare / Q000706:statistics & numerical data*; D009735:Nursing Homes; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D010351:Patient Discharge; D020521:Stroke / Q000191:economics; D000071939:Stroke Rehabilitation; D014481:United States