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Sheldon M. Retchin, MD, MSPH; Randall S. Brown, PhD; Shu-Chuan Jennifer Yeh, MS; Dexter Chu; Lorenzo Moreno, PhD

JAMA. 1997;278(2):119-124.

Abstract
Context.
—Increasing numbers of Medicare beneficiaries have been enrolling in health maintenance organizations (HMOs) because HMO participation reduces out-of-pocket expenses, and the federal government views HMOs as a way to contain Medicare costs. However, results comparing outcomes and quality of care in HMOs vs fee for service (FFS) have been mixed, and outcomes after stroke have not been adequately assessed.

Objective.
—To compare discharge destinations and survival rates following stroke in Medicare HMOs with similar FFS settings.

Design.
—An observational study for 2 groups evaluating stroke patients' discharge destinations and survival times from the date of hospital admission.

Setting.
—A total of 19 HMOs were selected from 12 states. The FFS sample was drawn 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 records on demographics, clinical characteristics of stroke, comorbid illnesses, and discharge destinations following hospitalization. Data on survival 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 date of hospital admission.

Results.
—There were 109 patients who died during the hospitalization (49 HMO, 12.2%; 60 FFS, 14.7%), and a total of 410 patients had died by the end of follow-up (191 HMO, 47.5%; 219 FFS, 53.7%). Approximately one fourth of both groups had do-not-resuscitate 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 homes (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 FFS groups (relative risk, 0.96; 95% confidence interval, 0.73-1.26; P=.77).

Conclusions.
—Patients in Medicare HMOs who experience strokes are more likely to be discharged to nursing homes and less likely to go to rehabilitation facilities following the acute event. However, they have similar survival patterns compared with comparable patients in FFS settings after adjusting for other factors.

Author Affiliations
From the Department of Internal Medicine, School of Medicine (Dr Retchin), and the Department of Health Administration, School of Allied Health (Ms Yeh), Virginia Commonwealth University, Richmond; and Mathematica Policy Research Inc, Princeton, NJ (Drs Brown and Moreno and Mr Chu).

Footnotes
The conclusions in this paper are thoseof the authors and do not reflect the views of the Health Care Financing Administration, Virginia Commonwealth University, or Mathematica Policy Research Inc.

Reprints: Sheldon M. Retchin, MD, MSPH. Box 980270, Richmond, VA 23298-0270.

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