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Long-term Care

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Greater Medicare HMO penetration is associated with a shift in elderly stroke deaths from hospital to non-hospital settings

Medicare HMO penetration in a local health care market does not appear to affect in-hospital or overall stroke mortality rates among the elderly. However, increased Medicare HMO penetration is associated with a shift in stroke deaths from hospitals to nursing homes or residences, according to a study supported in part by the Agency for Healthcare Research and Quality (T32 HS00032). HMOs may encourage providers to avoid hospitalizing patients who are unlikely to do well with acute care (such as severely demented individuals with another stroke in a series of strokes) and to discharge them faster when they are admitted. More stroke deaths out of the hospital could also reflect greater appreciation for patient preference, explain the researchers.

They used data from the Nationwide Inpatient Sample of the AHRQ Healthcare Cost and Utilization Project and mortality data from the National Vital Statistics System from 1993 to 1998 to examine the association between Medicare HMO penetration (based on HMO enrollment files) and in-hospital and overall mortality rates among older people insured through Medicare. The hospital discharge sample included 365,479 stroke hospitalizations in 1,327 hospitals in 17 States.

The proportion of stroke deaths occurring in the hospital decreased from 64 percent in 1993 to 58.4 percent in 1998, but the overall population stroke death among older people remained stable at 2.6 per 10,000 people. Medicare total and IPA (Individual Practice Association) HMO penetration grew steadily during the same period, while non-IPA HMO penetration grew at a slower pace. None of the three Medicare HMO penetration variables (total, IPA and non-IPA) was associated with in-hospital or overall population stroke mortality rates. However, a 10- percentage point increase in Medicare total or IPA HMO penetration was associated with a 1 percentage point decrease in the proportion of stroke deaths occurring in hospitals.

See "Medicare HMO penetration and mortality outcomes of ischemic stroke," by John Bian, Ph.D., William H. Dow, Ph.D., and David B. Matchar, M.D., in the January 2006 American Journal of Managed Care 12(1), pp. 58-64.

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