Functional outcomes of posthospital care for stroke and hip fracture patients under Medicare

BACKGROUND: Medicare's introduction of the Prospective Payment System for h ospitals has led to tremendous growth in ways of providing posthospital car e. Despite substantial differences in costs per episode of care, the type o f posthospital care that produces the best results for specific types of pa tients is not clear. This study analyzed the outcomes of different types of posthospital care for a cohort of older Medicare patients (who had diagnos es associated with the use of a range of posthospital care modalities) for up to a year after hospital discharge. METHODS: Medicare patients hospitalized with strokes and hip fractures were enrolled consecutively just before discharge from 52 hospitals in three ci ties in 1988-1989. These diagnosis-related groups were chosen because patie nts were discharged to all three major types of Medicare-supported posthosp ital care. Patients were interviewed in-person before discharge and again a t 6 weeks, 6 months, and 1 year after discharge. The functional outcomes of posthospital care were evaluated by the instrumental variables estimation approach to correct for selection bias caused by nonrandom treatment assign ment The impacts of discharge locations on the functional outcomes were exa mined by one-way analyses of variance (ANOVA). RESULTS: In general, the more disabled patients went to nursing homes and r ehabilitation, but the overlap in distribution was sufficient to conduct th e analyses. Stroke patients discharged to nursing homes had the highest mor tality rate (P < .01). Stroke patients discharged to home health had the lo west rehospitalization rates (P < .05) Hip fracture discharged to home heal th care had the highest adjusted rehospitalization rate, whereas those disc harged to nursing homes had the lowest adjusted rehospitalization rate (P < .05). For stroke patients, posthospital care in rehabilitation facilities or home health care was associated with significantly better functional imp rovement compared with stroke patients discharged elsewhere. However, funct ional outcomes deteriorated by 1 year posthospitalization among stroke pati ents who received their posthospital care at nursing homes or received no f ormal posthospital care. For hip fracture patients, all four types of posth ospital care were associated with functional improvement, but patients disc harged to rehabilitation facilities experienced the most functional improve ment. CONCLUSIONS: The choice of posthospital care can influence the course of Me dicare patients. Careful attention should be paid to how hospital discharge decisions are made and to the financial incentives for different types of posthospital care provided under the current payment system. The current su pply of nursing homes is not well suited to the demands of posthospital car e.