Rehospitalization and survival for stroke patients in managed care and traditional Medicare plans

Med Care. 2005 Sep;43(9):902-10. doi: 10.1097/01.mlr.0000173597.97232.a0.


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.

Objectives: We sought to compare utilization and outcomes after stroke in Medicare HMO and FFS.

Design: We reviewed administrative data in 11 regions from Medicare and a large national health plan.

Subjects: 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.

Measures: 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.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Confidence Intervals
  • Fee-for-Service Plans / economics
  • Fee-for-Service Plans / standards*
  • Female
  • Health Maintenance Organizations / economics
  • Health Maintenance Organizations / standards*
  • Humans
  • Male
  • Medical Records Systems, Computerized / statistics & numerical data
  • Medicare / statistics & numerical data*
  • Middle Aged
  • Odds Ratio
  • Outcome Assessment, Health Care
  • Outcome and Process Assessment, Health Care
  • Patient Readmission / economics
  • Patient Readmission / statistics & numerical data*
  • Proportional Hazards Models
  • Retrospective Studies
  • Stroke / economics*
  • Stroke / mortality*
  • Survival Analysis
  • Time Factors
  • United States / epidemiology