Five-year survival in a Program of All-inclusive Care for Elderly compared with alternative institutional and home- and community-based care.
BACKGROUND
Community-based services are preferred to institutional care for people requiring long-term care (LTC). States are increasing their Medicaid waiver programs, although Program of All-Inclusive Care For Elderly (PACE)-prepaid, community-based comprehensive care-is available in 31 states. Despite emerging alternatives, little is known about their comparative effectiveness.


METHODS
For a two-county region of South Carolina, we contrast long-term survival among entrants (n = 2040) to an aged and disabled waiver program, PACE, and nursing homes (NHs), stratifying for risk. Participants were followed for 5 years or until death; those lost to follow-up or surviving less than 5 years as on August 8, 2005 were censored. Analyses included admission descriptive statistics and Kaplan-Meier curves. To address cohort risk imbalance, we employed an established mortality risk index, which showed external validity in waiver, PACE, and NH cohorts (log-rank tests = 105.42, 28.72, and 52.23, respectively, all p < .001; c-statistics = .67, .58, .65, p < .001).


RESULTS
Compared with waiver (n = 1,018) and NH (n = 468) admissions, PACE participants (n = 554) were older, more cognitively impaired, and had intermediate activities of daily living dependency. PACE mortality risk (72.6% high-to-intermediate) was greater than in waiver (58.8%), and similar to NH (71.6%). Median NH survival was 2.3 years. Median PACE survival was 4.2 years versus 3.5 in waiver (unstratified, log rank = .394; p = .53), but accounting for risk, PACE's advantage is significant (log rank = 5.941 (1); p = .015). Compared with waiver, higher risk admissions to PACE were most likely to benefit (moderate: PACE median survival = 4.7 years vs waiver 3.4; high risk: 3.0 vs 2.0).


CONCLUSIONS
Long-term outcomes of LTC alternatives warrant greater research and policy attention.
Wieland
Darryl
D
Division of Geriatrics, Department of Medicine, University of South Carolina School of Medicine, Columbia, SC, USA. darryl.wieland@palmettohealth.org
Boland
Rebecca
R
Baskins
Judith
J
Kinosian
Bruce
B
D000368:Aged; D003153:Community Health Services; D003191:Comprehensive Health Care / Q000458:organization & administration*; D005260:Female; D006299:Health Services for the Aged / Q000458:organization & administration*; D006707:Homes for the Aged; D006801:Humans; D053208:Kaplan-Meier Estimate; D008134:Long-Term Care / Q000458:organization & administration; D008297:Male; D013022:South Carolina; D016019:Survival Analysis