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RRP 12-455 – HSR&D Study

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RRP 12-455
System Dynamics to Model Resource Utilization and Transitions after Stroke
Dawn M. Bravata MD
Richard L. Roudebush VA Medical Center, Indianapolis, IN
Indianapolis, IN
Funding Period: March 2013 - August 2014

BACKGROUND/RATIONALE:
Stroke is both a common and costly problem in the Veteran population. Approximately 6500 Veterans are hospitalized in a Department of Veterans Affairs (VA) hospital with an acute ischemic stroke every year. However, little is known about transitions in care that occur in the post-stroke period for Veterans who survive their index event.

OBJECTIVE(S):
The purpose of this project was to describe care trajectories and associated use and costs of care over a 12-month period after discharge for VA patients with ischemic stroke. We sought to: (1) describe care and health status trajectories and associated use and costs of care after discharge from an index stroke admission; and (2) examine the relationships between inpatient stroke care quality and cost of care.

METHODS:
We used data from the VA Office of Performance Measurement (OPM) Stroke Special Project. As part of that study, medical records were reviewed for a sample of 5000 Veterans who were admitted to a VA hospital in fiscal year 2007 with ischemic stroke. Chart review data were used to measure pass rates on nine quality indicators (QIs) that included processes of care that spanned the hospitalization from the early Emergency Department period through the inpatient stay.

The Stroke Special Project chart review data were merged with Medicare Data, and a variety of VA data sources including Decision Support System (DSS) and Health Economics Resource Center (HERC) cost data. We used these VA and non-VA data to examine health care utilization for the Veterans in the Stroke Special Project cohort including: acute, intermediate, and long-term care utilization; re-hospitalization; mortality; and VA and Medicare costs.

We used latent class growth curve analysis (LCGA) to identify subpopulations of stroke patients who had similar trajectories in their transitions between care settings. Because total costs were not normally distributed and were clustered within VA facilites, we used a generalized linear mixed model with an appropriate distribution and link transformation to model costs.

FINDINGS/RESULTS:
A total of 3811 patients were included in the analysis.

TRAJECTORIES. Half of the patients had a mild stroke, 40% a moderate stroke, and 10% a severe stroke. According to their total Functional Independence Measure (FIM) scores, 37% were independent, 45% had modified dependence, and 18% completely dependent. Over the course of the 1-year post-stroke, 50% had at least one hospitalization, 7% hospice care, and 16% died. In terms of rehabilitation care within 90-days of discharge: 51% received no rehabilitation care, 29% outpatient rehabilitation, 21% nursing home rehabilitation, 8% inpatient rehabilitation, and 4% home health rehabilitation. The majority of rehabilitation services were provided by the VA and not Medicare. Five distinct trajectories were identified: rapid recovery (49%), slow recovery (15%), long-term nursing home care (13%), long-term home care (9%), and an unstable trajectory (14%).

COSTS. The mean acute costs were $13,626 (standard deviation, $21,606) and median acute costs were $8,577 (IQR $5,335-$14,763). Passing on five of the QIs was associated with higher mean costs: fall risk assessment ($795); dysphagia screening ($2,600); early ambulation ($2,892); rehabilitation needs assessment ($3,281); DVT prophylaxis ($5,235); and thrombolytic therapy ($7,927). Passing on three of the QIs was associated with lower costs: NIHSS documentation (-$1,827); pressure ulcer assessment (-$2,145); and antithrombotic medication at (-$3,509). Two processes of care were associated with neither higher nor lower mean inpatient costs: early ambulation and fall risk assessment. The mean total annual payments for inpatient care, nursing home care, home care, and rehabilitation services was $29,899, however these costs varied considerably by trajectory; patients in the rapid recovery trajectory had mean costs of approximately $10,000 whereas the unstable and long-term nursing home care groups had costs greater than $60,000.

IMPACT:
The finding that the majority of rehabilitation services are provided in the nursing home setting as opposed to the in-patient rehabilitation setting was suprising; we are planning a follow-up study to evaluate whether Veterans are receiving the rehabilitation care that they need post-stroke. The finding that there are five distinct post-stroke trajectories is novel; we are planning to validate these trajectories in a prospective project.

PUBLICATIONS:

Journal Articles

  1. Arling G, Ofner S, Reeves MJ, Myers LJ, Williams LS, Daggy JK, Phipps MS, Chumbler N, Bravata DM. Care Trajectories of Veterans in the 12 Months After Hospitalization for Acute Ischemic Stroke. Circulation. Cardiovascular quality and outcomes. 2015 Oct 1; 8(6 Suppl 3):S131-40.
Journal Other

  1. Arling G, Ofner S, Myers L, Daggy J, Reeves M, Williams LS, Bravata DM. Care Trajectories and Costs after Ischemic Stroke for Patients in the Veterans Health Administration. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2015 Apr 1; 46(4):AWP296.
Conference Presentations

  1. Arling G, Ofner S, Myers L, Daggy J, Reeves M, Williams LS, Bravata DM. Care Trajectories and Costs after Ischemic Stroke for Patients in the Veterans Health Administration. Poster session presented at: American Heart Association / American Stroke Association International Stroke Conference; 2015 Feb 11; Nashville, TN.


DRA: Cardiovascular Disease
DRE: Prognosis
Keywords: QUERI Implementation
MeSH Terms: none

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