QUALITY OF CARE FOR HOSPITALIZED DEPRESSED ELDERLY PATIENTS BEFORE AND AFTER IMPLEMENTATION OF THE MEDICARE PROSPECTIVE PAYMENT SYSTEM

Objective: The authors evaluated the impact of Medicare's Prospective Payment System on aspects of quality of care and outcomes for depresse d elderly inpatients in acute-care general medical hospitals. Method: The depressed elderly inpatients (N=2,746) were hospitalized in 297 ac ute-care general medical hospitals. The authors used a retrospective b efore-and-after design, controlling for differences over time in sickn ess at admission. Quality of care and outcomes were assessed through c linical review of explicit and implicit information in the medical rec ords; secondary data sources provided information on postdischarge out comes. Results: After implementation of the prospective payment system 1) a higher percentage of patients had clinically appropriate acute-c are admissions; 2) the initial assessment of psychological status by t he treating provider was more complete; 3) the quality of psychotropic medication management, as rated by the study psychiatrists, improved; 4) the rates of any inpatient medical or psychiatric complication, of discharge to another hospital or a nursing home, and of inpatient rea dmission declined; and S) there was no marked change in the percentage of patients rated by study clinicians as having acceptable overall cl inical status at discharge or the rate of mortality 1 year after admis sion. Conclusions: After the implementation of the Medicare Prospectiv e Payment System, the quality of care for depressed elderly inpatients improved and there was no marked increase in adverse clinical outcome s. Despite these gains, after implementation the quality of care was m oderate at best and over one-third of the patients had unacceptable cl inical status at discharge.