OUTCOMES OF STROKE PATIENTS IN MEDICARE FEE-FOR-SERVICE AND MANAGED CARE

Context.-Increasing numbers of Medicare beneficiaries have been enroll ing in health maintenance organizations (HMOs) because HMO participati on reduces out-of-pocket expenses, and the federal government views HM Os as a way to contain Medicare costs. However, results comparing outc omes and quality of care in HMOs vs fee for service (FFS) have been mi xed, and outcomes after stroke have not been adequately assessed. Obje ctive.-To compare discharge destinations and survival rates following stroke in Medicare HMOs with similar FFS settings. Design.-An observat ional study for 2 groups evaluating stroke patients' discharge destina tions and survival times from the date of hospital admission. Setting. -A total of 19 HMOs were selected from 12 states. The FFS sample was d rawn from the same geographic areas. Patients.-The sample included 402 HMO patients from 71 hospitals and 408 FFS patients from 60 hospitals . Process and Outcome Measures.-Data were abstracted from medical reco rds on demographics, clinical characteristics of stroke, comorbid illn esses, and discharge destinations following hospitalization. Data on s urvival were obtained from Medicare files and included 25 to 37 months of follow-up (median, 30.4 months, HMO; 31.1 months, FFS) from the da te of hospital admission. Results.-There were 109 patients who died du ring the hospitalization (49 HMO, 12.2%; 60 FFS, 14.7%), and a total o f 410 patients had died by the end of follow-up (191 HMO, 47.5%; 219 F FS, 53.7%). Approximately one fourth of both groups had do-not-resusci tate orders (HMO, 25.4%; FFS, 27.9%; P=.68). After controlling for age , marital status, and characteristics of dependency at discharge, HMO patients were more likely than FFS patients to be sent to nursing home s (HMO, 41.8%; FFS, 27.9%; P=.001) and less likely to be discharged to rehabilitation hospitals or units (HMO, 16.2%; FFS, 23.4%; P=.03). At follow-up, no significant differences in relative risk of dying were found between HMO and I-FS groups (relative risk, 0.96; 95% confidence interval, 0.73-1.26; P=.77). Conclusions.-Patients in Medicare HMOs w ho experience strokes are more likely to be discharged to nursing home s and less likely to go to rehabilitation facilities following the acu te event, However, they have similar survival patterns compared with c omparable patients in FFS settings after adjusting for other factors.