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Grant Miller: Managerial Incentives in Public Service Delivery
Skolarus, L., L. Morgenstern, D. Zahuranec, James Burke, Kenneth M. Langa, and T. Iwashyna. 2013. "Acute care and long-term mortality among elderly patients with intracerebral hemorrhage who undergo chronic life-sustaining procedures." Journal of Stroke and Cerebrovascular Diseases, 22(1): 15-21.
Little is known about patients with intracerebral hemorrhage (ICH) who undergo chronic life-sustaining procedures. We sought to explore variations in treatment, Medicare payments, and mortality among elderly patients with ICH who received a feeding tube, a tracheostomy, or neither chronic life-sustaining procedure. Medicare Provider Analysis and Review files from 2004 linked to Center for Medicaid and Medicare Services denominator files through January 2005 were analyzed. Patients over age 65 years with a primary diagnosis of ICH based on discharge code (ICD-9-CM 431) were divided into those who underwent tracheostomy, those who underwent feeding tube placement but not tracheostomy, and those who underwent neither procedure. Thirty-day and 1-year survival rates were estimated using Kaplan-Meier methods. Among the 32,210 patients studied, 6% underwent feeding tube placement, and 2.5% underwent tracheostomy. Compared with the patients who did not undergo a chronic life-sustaining procedure, those who underwent tracheostomy had a longer length of stay (median, 25 days vs 4 days; P < .01) and greater Medicare spending (median, $81,479 vs $6,008; P < .01) during their initial hospitalization. The 30-day and 1-year cumulative mortality risks were 47% and 59%, respectively, in patients who did not undergo a chronic life-sustaining procedure, 21% and 53% in patients who underwent feeding tube placement, and 19% and 65% in those who underwent tracheostomy (P < .01, log-rank test across the 3 groups). Our findings show high 1-year mortality among elderly patients with ICH, even in those who undergo chronic life-sustaining procedures. Medicare payments for patients who undergo tracheostomy are substantial. More information about functional outcomes is needed.
PMCID: PMC3202018. (Pub Med Central)