title: Rehospitalization and survival for stroke patients in managed care and traditional Medicare plans.
abstract: BACKGROUND
  Stroke affects more than 500,000 older persons each year in the United States, but no studies have compared older stroke patients in Medicare health maintenance organizations (HMOs) and fee-for-service (FFS) after recent changes in FFS reimbursement.
  
  
  OBJECTIVE
  We sought to compare utilization and outcomes after stroke in Medicare HMO and FFS.
  
  
  METHODS
  We reviewed administrative data in 11 regions from Medicare and a large national health plan.
  
  
  METHODS
  We studied Medicare beneficiaries 65 years and older discharged with ischemic stroke during 1998-2000, ie, 4816 HMO patients and a random sample of 4187 FFS patients from 422 hospitals.
  
  
  METHODS
  We measured survival, rehospitalization, length of stay, discharge destination, and warfarin use.
  
  
  RESULTS
  Overall, HMO patients were younger, male, non-Caucasian, and had fewer comorbid conditions. When compared with FFS patients, HMO patients were more likely to be rehospitalized within 30 days for a primary diagnosis of ischemic stroke (Adjusted Hazard Ratio = 1.45, 95% Confidence Interval [CI] 1.14-1.83) or ill-defined conditions (eg, rehabilitation services) (2.87, 95% CI 1.85-4.46) and less likely to be rehospitalized for fluid and electrolyte disorders (0.54, 95% CI 0.34-0.87) or circulatory/respiratory problems (0.77, 95% CI 0.60-0.98). There were no consistent differences in 30-day mortality or in 1-year rehospitalization or mortality for 30-day survivors. HMO patients also were much less likely to be discharged to rehabilitation facilities, slightly less likely to be discharged to skilled nursing facilities and to have a shorter length of stay, and did not differ in the use of home care services or warfarin use when compared with FFS patients.
  
  
  CONCLUSIONS
  Traditional measures of quality such as 30-day rehospitalization may not be valid when comparing HMO and FFS patients if differences might reflect an alternative service mix. Utilization of post-acute care for FFS patients appears similar to HMO patients except for discharge to rehabilitation facilities.
authors.affiliation: Department of Population Health Sciences, University of Wisconsin-Madison Medical School, Madison, Wisconsin 53705-2397, USA. maureensmith@wisc.edu
authors.forename: Maureen A
authors.initials: MA
authors.lastname: Smith
authors.forename: Jennifer R
authors.initials: JR
authors.lastname: Frytak
authors.forename: Jinn-Ing
authors.initials: JI
authors.lastname: Liou
authors.forename: Michael D
authors.initials: MD
authors.lastname: Finch
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016001:Confidence Intervals; D018588:Fee-for-Service Plans / Q000191:economics / Q000592:standards*; D005260:Female; D006279:Health Maintenance Organizations / Q000191:economics / Q000592:standards*; D006801:Humans; D008297:Male; D016347:Medical Records Systems, Computerized / Q000706:statistics & numerical data; D006278:Medicare / Q000706:statistics & numerical data*; D008875:Middle Aged; D016017:Odds Ratio; D017063:Outcome Assessment, Health Care; D010043:Outcome and Process Assessment, Health Care; D010359:Patient Readmission / Q000191:economics / Q000706:statistics & numerical data*; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D020521:Stroke / Q000191:economics* / Q000401:mortality*; D016019:Survival Analysis; D013997:Time Factors; D014481:United States / Q000453:epidemiology