title: A comparison of Medicare fee-for-service and a group-model HMO in the inpatient management and long-term survival of elderly individuals with syncope.
abstract: OBJECTIVE
  To compare the management and survival of elderly patients hospitalized with syncope in 2 healthcare delivery systems.
  
  
  METHODS
  Retrospective cohort.
  
  
  METHODS
  Using hospitalization records from Medicare and a group-model health maintenance organization (HMO) in Oregon, we identified individuals with an admission or discharge diagnosis of syncope between 1992 and 1994. Among patients 65 years or older (median age = 79 years), we randomly selected a sample of the standard Medicare patients (primarily fee-for-service; n = 473) and all of the group-model HMO patients (n = 583). Use of inpatient testing and consultation was ascertained by chart review; all-cause mortality was obtained from the National Death Index.
  
  
  RESULTS
  Median diagnostic testing and consultation costs were the same (P = .35) in the standard Medicare population ($643) and the HMO population ($619), although the use of specific tests differed. More cardiovascular syncope was identified in the Medicare population (23% vs 18%; P = .02). Inpatient, 30-day, 1-year, and 4-year mortality rates were higher in the Medicare population (1.7%, 3.8%, 16.7%, and 50.6% respectively) than in the HMO population (0.7%, 1.5%, 13.2%, and 41.8%). After adjusting for age, gender, comorbidity, diagnostic testing, and administrative factors, the relative risk (RR) of dying was lower for group-model HMO patients (RR = 0.74; 95% confidence interval = 0.60, 0.91) than for standard Medicare patients (RR = 1.0).
  
  
  CONCLUSIONS
  The inpatient management of these elderly patients with syncope was similar in the group-model HMO and standard Medicare settings, but survival was better for the individuals in the HMO. The reason for the differential survival is not obvious and warrants additional study.
authors.affiliation: Department of Public Health and Preventative Medicine, Oregon Health Sciences University, Portland, USA. william.getchell@med.va.gov
authors.forename: W S
authors.initials: WS
authors.lastname: Getchell
authors.forename: G C
authors.initials: GC
authors.lastname: Larsen
authors.forename: C D
authors.initials: CD
authors.lastname: Morris
authors.forename: J H
authors.initials: JH
authors.lastname: McAnulty
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D018588:Fee-for-Service Plans / Q000191:economics / Q000592:standards*; D006279:Health Maintenance Organizations / Q000191:economics / Q000592:standards*; D006302:Health Services Research; D006801:Humans; D006278:Medicare / Q000458:organization & administration* / Q000592:standards; D009922:Oregon / Q000453:epidemiology; D010346:Patient Care Management; D012189:Retrospective Studies; D015996:Survival Rate; D013575:Syncope / Q000401:mortality / Q000628:therapy*; D016896:Treatment Outcome; D014481:United States