Medicare claims indicators of healthcare utilization differences after hospitalization for ischemic stroke: Race, gender, and caregiving effects (original) (raw)
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JAMA Network Open
IMPORTANCE Black and Hispanic US residents are disproportionately affected by stroke incidence, and patients with dual eligibility for Medicare and Medicaid may be predisposed to more severe strokes. Little is known about differences in stroke severity for individuals with dual eligibility, Black individuals, and Hispanic individuals, but understanding hospital admission stroke severity is the first important step for focusing strategies to reduce disparities in stroke care and outcomes. OBJECTIVE To examine whether dual eligibility and race and ethnicity are associated with stroke severity in Medicare beneficiaries admitted to acute hospitals with ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS This retrospective cross-sectional study was conducted using Medicare claims data for patients with ischemic stroke admitted to acute hospitals in the
Healthcare utilization and cost trajectories post-stroke: role of caregiver and stroke factors
BMC Health Services Research
Background: It is essential to study post-stroke healthcare utilization trajectories from a stroke patient caregiver dyadic perspective to improve healthcare delivery, practices and eventually improve long-term outcomes for stroke patients. However, literature addressing this area is currently limited. Addressing this gap, our study described the trajectory of healthcare service utilization by stroke patients and associated costs over 1-year post-stroke and examined the association with caregiver identity and clinical stroke factors. Methods: Patient and caregiver variables were obtained from a prospective cohort, while healthcare data was obtained from the national claims database. Generalized estimating equation approach was used to get the population average estimates of healthcare utilization and cost trend across 4 quarters post-stroke. Results: Five hundred ninety-two stroke patient and caregiver dyads were available for current analysis. The highest utilization occurred in the first quarter post-stroke across all service types and decreased with time. The incidence rate ratio (IRR) of hospitalization decreased by 51, 40, 11 and 1% for patients having spouse, sibling, child and others as caregivers respectively when compared with not having a caregiver (p = 0.017). Disability level modified the specialist outpatient clinic usage trajectory with increasing difference between mildly and severely disabled subgroups across quarters. Stroke type and severity modified the primary care cost trajectory with expected cost estimates differing across second to fourth quarters for moderately-severe ischemic (IRR: 1.67, 1.74, 1.64; p = 0.003), moderately-severe nonischemic (IRR: 1.61, 3.15, 2.44; p = 0.001) and severe non-ischemic (IRR: 2.18, 4.92, 4.77; p = 0.032) subgroups respectively, compared to first quarter. Conclusion: Highlighting the quarterly variations, we reported distinct utilization trajectories across subgroups based on clinical characteristics. Caregiver availability reducing hospitalization supports revisiting caregiver's role as potential hidden workforce, incentivizing their efforts by designing socially inclusive bundled payment models for post-acute stroke care and adopting family-centered clinical care practices.
American journal of epidemiology, 2016
We described the linkage of primary data with administrative claims using the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study and Medicare. REGARDS study data were linked with Medicare claims by use of Social Security numbers. We compared REGARDS participants by Medicare linkage status, having fee-for-service (FFS) coverage or not, and with a 5% sample of Medicare beneficiaries who had FFS coverage in 2005, overall, by age (45-64 and ≥65 years), and by race. Among REGARDS participants who were ≥65 years of age, 80% had data linked to Medicare on their study-visit date (64% with FFS coverage). No differences except race and sex were present between REGARDS participants without Medicare linkage and those with data linked to Medicare with and without FFS coverage. After the age-sex-race adjustment, comorbid conditions and health-care utilization were similar for those with FFS coverage in the REGARDS study and the 5% sample of Medicare beneficiaries. Among REGAR...
Racial/ethnic disparities in access to physician care and medications among US stroke survivors
Neurology, 2010
Background: Mexican Americans and non-Hispanic blacks have higher stroke recurrence rates and lower rates of secondary stroke prevention than non-Hispanic whites. As a potential explanation for this disparity, we assessed racial/ethnic differences in access to physician care and medications in a national sample of US stroke survivors. Methods: Among all 4,864 stroke survivors aged Ն45 years who responded to the National Health Interview Survey years 2000-2006, we compared access to care within the last 12 months by race/ethnicity before and after stratification by age (45-64 years vs Ն65 years). With logistic regression, we adjusted associations between access measures and race/ethnicity for sex, comorbidity, neurologic disability, health status, year, income, and health insurance. Results: Among stroke survivors aged 45-64 years, Mexican Americans, non-Hispanic blacks, and non-Hispanic whites reported similar rates of no generalist physician visit (approximately 15%) and inability to afford medications (approximately 20%). However, among stroke survivors aged Ն65 years, Mexican Americans and blacks, compared with whites, reported greater frequency of no generalist visit (15%, 12%, 8%; p ϭ 0.02) and inability to afford medications (20%, 11%, 6%; p Ͻ 0.001). Mexican Americans and blacks more frequently reported no medical specialist visit (54%, 49%, 40%; p Ͻ 0.001) than did whites and rates did not differ by age. Full covariate adjustment did not fully explain these racial/ethnic differences. Conclusions: Among US stroke survivors at least 65 years old, Mexican Americans and blacks reported worse access to physician care and medications than whites. This reduced access may lead to inadequate risk factor modification and recurrent stroke in these high-risk minority groups.
Disparities in Acute Stroke Severity, Outcomes, and Care Relative to Health Insurance Status
Journal of Stroke and Cerebrovascular Diseases, 2014
Background: To examine the differences in risk factors and length of hospital stay (LOS) between the insured and uninsured stroke patients, identifying the root causes of increasing hospital stay. Methods: Retrospective analysis of stroke registry data of acute stroke patients (N 5 19,255) was analyzed to compare risk factors, severity, outcome, and LOS by insurance status. Chart review of patients from a comprehensive stroke center (N 5 3290) was studied in greater detail for causes of extended length of stay. Results: The uninsured patients had poorer control of risk factors and statistically significantly (P ,.0001) higher initial stroke severity, mortality, and LOS as compared with insured patients (3.8 versus 4.5 days, respectively). The increased length of stay was largely accounted for by the inability to transfer uninsured patients to inpatient rehabilitation settings. Conclusion: This study highlights the need for public policies that provide funding for both primary stroke prevention and poststroke rehabilitation. Key Words: Cerebrovascular diseaseinsurance status-length of stay-stroke-health services research.
2011
Americans, but few prospective population-based studies have systematically examined demographic differences on long-term stroke outcomes. Race and gender differences in 1-year stroke outcomes were examined using an epidemiologically derived sample of first-time stroke survivors from the national REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Methods-Participants of REGARDS who reported a first-time stroke event during regular surveillance calls were interviewed by telephone and then completed an in-home evaluation approximately 1 year after the verified first-time stroke event (Nϭ112). A primary family caregiver was also enrolled and interviewed for each stroke survivor. Measures from the in-home evaluation included previously validated stroke outcomes assessments of neurological deficits, functional impairments, and patient-reported effects of stroke in multiple domains.
Stroke; a journal of cerebral circulation, 2014
Mounting evidence points to a decline in stroke incidence. However, little is known about recent patterns of stroke hospitalization within the buckle of the stroke belt. This study aims to investigate the age- and race-specific secular trends in stroke hospitalization rates, inpatient stroke mortality rates, and related hospitalization charges during the past decade in South Carolina. Patients from 2001 to 2010 were identified from the State Inpatient Hospital Discharge Database with a primary discharge diagnosis of stroke (International Classification of Diseases, Ninth Revision codes: 430-434, 436, 437.1). Age- and race-stroke-specific hospitalization rates, hospital charges, charges associated with racial disparity, and 30-day stroke mortality rates were compared between blacks and whites. Of the 84,179 stroke hospitalizations, 31,137 (37.0%) were from patients aged<65 years and 29,846 (35.5%) were blacks. Stroke hospitalization rates decreased in the older population (aged≥65...
Disparities in Outcomes Among Patients With Stroke Associated With Insurance Status
Stroke, 2007
Background and Purpose-Despite well-documented discrepancies in many clinical conditions across insurance groups, limited research has examined insurance-related disparities for patients with stroke. This study examined the relationship between insurance status and hospital care for patients with stroke. Methods-Discharges with intracerebral hemorrhage and acute ischemic stroke were abstracted from the 2002 National Inpatient Sample. Neurologic impairment status and mortality were examined. Results-Compared with privately insured patients, uninsured patients had a higher level of neurologic impairment, a longer average length of hospital stay, and higher mortality risk. For patients with intracerebral hemorrhage and acute ischemic stroke, mortality risk of uninsured patients was approximately 24% and 56% higher, respectively, than that of their privately insured peers. Conclusions-Policy should promote access to outpatient and preventive care for uninsured patients so risk factors such as hypertension can be detected and treated during early, asymptomatic stages. Further research is needed to evaluate the extent to which differences in outcomes are attributable to differences in severity level on admission.
Stroke, 2011
Background and Purpose— Stroke is the second leading cause of hospital admission among older adults in the United States. However, little is known regarding contemporary ischemic stroke mortality and rehospitalization rates for Medicare beneficiaries and how they vary by hospital. Methods— We analyzed outcome data from 91 134 Medicare fee-for-service beneficiaries treated at 625 Get With The Guidelines–Stroke hospitals between April 2003 and December 2006. Within each hospital, 30-day and 1-year death or all-cause readmission rates were calculated with and without risk adjustment. Results— In this cohort, mean age was 79.3 years, 58% were female, and 82% were white. In-hospital, 30-day, and 1-year unadjusted mortality from admission were 6.1%, 14.1%, and 31.1%, respectively, for participating hospitals. The median hospital-level 30-day unadjusted death or readmission rate after discharge was 21.4% (10th to 90th 14.4% to 28.6%). The overall rate of death or rehospitalization within 1...
Effect of insurance status on postacute care among working age stroke survivors
Neurology, 2012
Objective: Utilization of postacute care is associated with improved poststroke outcomes. However, more than 20% of American adults under age 65 are uninsured. We sought to determine whether insurance status is associated with utilization and intensity of institutional postacute care among working age stroke survivors.