Rehospitalization for Stroke among Elderly TIA Patients

Transcription

1 Rehospitalization for Stroke among Elderly TIA Patients By William Buczko, PhD Centers for Medicare & Medicaid Services 7500 Security Blvd. C Baltimore, MD Phone: (410) , Fax: (410) The views expressed in this paper are those of the author and are not necessarily those of the Department of Health and Human Services or the Centers for Medicare & Medicaid Services.

2 ABSTRACT Transient ischemic attack (TIA) is a comparatively mild form of stroke with low incidences of subsequent institutionalization and mortality. This study is concerned with determining if elderly Medicare beneficiaries newly hospitalized for TIA in FY 1999 are likely to be hospitalized for stroke during the FY FY 2004 period. Also, are rehospitalized beneficiaries likely to be treated for a more severe form of stroke? MEDPAR inpatient hospital discharge data are examined for Medicare fee-for-service beneficiaries age 65 or over discharged during FY 1999 with a principal diagnosis of ICD-9-CM codes and no prior stroke hospitalization in FY 1997 or FY 1998 (N=96,755). FY MEDPAR data were examined for hospitalizations for ICD-9- CM codes Hospitalization patterns are examined by age, race and sex. In-hospital and post-discharge survival are also examined. Only 6.9% of the cohort of beneficiaries hospitalized for TIA in FY 1999 were subsequently hospitalized for any form of stroke during FY 2000 (n=6685). Nearly 56% of those rehospitalized had a more severe form of stroke (i.e. hemorrhage, infarction, arterial occlusion, non-specific) while 44% were rehospitalized for TIA. While little difference in short-term post discharge survival was noted, FY 2000 rehospitalized beneficiaries had increasingly lower survival rates from 2 to 5 years post-discharge.

3 Introduction This study examines the incidence of hospitalizations for stroke among elderly Medicare beneficiaries who were hospitalized previously for a Transient Ischemic Attack (TIA). The major question to be answered is whether TIA is a significant precursor of additional TIA incidents or more serious forms of cerebrovascular disease? Stroke in the Medicare population is a leading cause of death and is also a cause of physiologic, functional and psychological impairment that often results in institutionalization and functional decline. Conditions commonly classified as strokes vary in incidence, severity and mortality. Hemorrhagic strokes (ICD-9-CM codes ) involve cranial blood vessels rupturing. These strokes are the most severe and are associated with the highest rates of mortality (Ayala, et al. 2003; Collins, et al. 2003). Most cases of stroke do not involve hemorrhage and are labeled ischemic strokes. These strokes (ICD-9-CM codes ) involve arterial occlusions, thrombosis or embolisms either with or without infarction. Ischemic strokes with infarctions are far more severe and have higher rates of mortality than those without accompanying infarction. Acute but non-specific or ill-defined cerebrovascular accidents (ICD-9-CM code 436) also are very severe and are associated with high mortality rates despite their unclear clinical description. Stroke hospitalization rates increased during the last 20 years. Common comorbidities in stroke patients are hypertension, diabetes, coronary heart disease and congestive heart failure (Fang and Alderman, 2001). Events such as transient cerebral ischemia (ICD-9-CM code 435), other/ill-defined cerebrovascular disease (ICD-9-CM code 437) and late effects of cerebrovascular disease (ICD-9- CM code 438) are counted as strokes in epidemiological estimates of stroke incidence despite their

4 lesser severity and far lower mortality in comparison with hemorrhagic or ischemic strokes (Williams, 2001; Davis, et. al. 2003). The vast majority of TIAs are brief with symptoms lasting 1 hour or less (Johnston and Hill, 2004). However, it is not clear if lesser cerebrovascular incidents such as TIA are necessarily precursors to either hemorrhagic or ischemic strokes. Many researchers have been concerned that TIA can be an indicator of future cerebrovascular events (Sacco, et al. 2006). Giles and Rothwell (2005) suggest that 25% of strokes annually in the United Kingdom are recurrent. Some of these may take the form of more serious hemorrhagic or ischemic strokes. Samsa, et. al, (1999) indicate that patients with recurrent strokes have a greater likelihood of past TIA, more comorbidies, higher costs, higher mortality, and poorer outcomes than patients hospitalized for their first stroke. Verro (2004) suggests that patients with recent TIAs are at high risk from brain infarction. Several studies have examined the risk of stroke after TIA and have found 90 day risk rates ranging from 10 30% (Johnston, et al, 2003; Johnson and Hill, 2004; Rothwell and Warlow, 2005). Increasing age is a major but under appreciated risk factor for future stroke (Verro, 2004) and is consistent with past studies indicating that stroke incidence, hospitalization rates and mortality increase with age (Fang and Alderman, 2001; Davis, et al. 2003) Diabetes, TIA duration greater than 10 minutes, motor weakness and speech impairment are also important risk factors. Risk factors tend to have a cumulative effect in raising risk level as high as 35% (Rothwell, et al 2006). Johnston and Hill (2004) indicate that risks are time dependent with a substantial portion of risk determined during the first 48 hours after TIA. African-Americans may, as a group, be more at risk for a future stroke rehospitalization after a TIA hospitalization since they have a greater incidence of stroke, greater likelihood of greater subsequent mortality and more

5 severe residual impairment than whites (Gillum, 1999; Ayala, et al. 2002; Horner, et al. 2003, Kennedy, 2005). Coull, et al. (2004) and Rothwell, et. al. (2006) suggest that TIA can be considered a warning event providing an opportunity to prevent future stroke. Few studies have examined mortality from TIA or stroke hospitalization for periods of time exceeding one year. Hankey, et al. (1991) found in a cohort of TIA patients a five year risk of stroke of 16% and a five year risk of death of 20.5%. Bravata et. al. (2003) found a 5 year cumulative mortality rate for TIA patients of 49.6%. A more recent study by van Wijk, et al (2005) indicated that, after a 10 year follow up, the risk of death was 34.1% and the risk of a vascular event was 35.8%. They found that risk of a vascular event was highest immediately after the initial cerebrovascular event and declined to a low point at 3 years and increased gradually in the years following. The risk estimates noted in these longitudinal studies are similar to those obtained for all types of strokes at 5 years and 10 years post stroke in Perth Australia (Hankey, et al. 2000; Hardie, et al. 2003). Giles and Rothwell (2006) indicate that recent data on the long-term cerebrovascular risk after TIA indicates increased likelihood of mortality and need for continued prevention efforts.

6 Data. MEDPAR inpatient hospital discharge data are examined for Medicare fee-for-service beneficiaries age 65 or over discharged during FY 1999 with a principal diagnosis of ICD-9-CM codes (Transient Ischemic Attack) and no prior stroke hospitalization in FY 1997 or FY 1998 (N=96,755). FY MEDPAR data were examined for hospitalizations for ICD-9- CM codes Hospitalization patterns are examined by age, race and sex. Source of admission, post-acute care use, in-hospital and post-discharge mortality are also examined. Data for Medicare managed care patients were not available and were excluded from this analysis. The FY 1999 Cohort There were 114,184 Medicare beneficiaries age 65 or older that were hospitalized for TIA during FY A total of 13,114 beneficiaries were hospitalized for a prior stroke during either FY1997 or FY These patients were excluded from the cohort, leaving 96,755 beneficiaries with no prior stroke hospitalizations in the two prior years. The average age of the beneficiaries in the FY 1999 cohort is 79.2 years of age (Table 1). Also, 26.5% of the cohort was 85 years old or older. Sixty two percent of the cohort was female. Eighty seven percent of the cohort was white while 9.9% were black and 1.8% was Hispanic. The average length of stay for the index TIA hospitalization for this cohort is 3.5 days during which $7,275 in total Medicare covered charges were amassed (Table 2). The data in Table 2 also indicate that nearly 74% of TIA hospitalizations for this cohort were admitted from the emergency room and over 2/3 of these admissions were coded as emergent. Only 6.8% of these admissions were coded as elective admissions. Slightly over 72% of these admissions were discharged to home, 9.6%

7 received home health services and 13.1% were discharged to skilled or intermediate nursing home care. Results Only 6.9% of the cohort of beneficiaries hospitalized for TIA in FY 1999 were rehospitalized for any form of stroke during FY 2000 (n=6685) (Table 3). In subsequent years, 5.1% of cohort beneficiaries were rehospitalized for any form of stroke during FY 2001 (n=4,893), 3.8% were rehospitalized during FY 2002 (n=3,698), 3.0% were rehospitalized during FY 2003 (n=2,934) and 2.4% were rehospitalized during FY 2004 (n=2,336). Nearly 18% of the beneficiaries hospitalized for TIA during 1999 (n=17,382) were rehospitalized for some form of stroke in at least one year from FY 2000 to FY The mean age of cohort members rehospitalized for stroke in subsequent years increased from 80.7 years (as of the index year) for FY 2000 rehospitalizations to 82.3 years for FY 2004 rehospitalizations (Table 3). The percentage of patients in the two oldest age groups tends to increase in each subsequent follow up year while the percentage of patients in the two youngest age groups decline during this period. These increases primarily represent the aging of the cohort. As Table 3 indicates, the sex distribution for those rehospitalized in each of the follow-up years contains a greater percentage of females ( %) than that of the index hospitalization period (62%). Blacks comprise a greater percentage of each follow-up year s rehospitalizations ( %) than their share of the cohort population in the index year (9%). Hispanics also comprise a slightly greater percentage of each follow-up year s rehospitalizations ( %) than their share of the cohort population in the index year (1.8%).

8 Lengths of stay for rehospitalizations during the follow-up period were longer (4.7 5 days) than for the index hospitalization (3.5 days) (Table 4). Total covered charges were substantially greater for rehospitalizations in each follow-up year and appear to increase over time from the index year. These data reflect the increased severity of rehospitalizations, as will be shown below. Rehospitalizations during the follow-up period often were for more severe forms of stroke. Nearly 56% of those rehospitalized during FY 2000 had a more severe form of stroke (i.e. hemorrhage, infarction, arterial occlusion, non-specific). This percentage increased to 61.9% of FY 2004 rehospitalizations (Table 4). Many of these rehospitalizations were for treatment of cerebral occlusion with infarction. In contrast, few rehospitalizations were for hemorrhagic strokes. From 38-44% of follow-up period rehospitalizations were for TIA. There were no indications of age or sex differences and the likelihood of rehospitalization for a more severe type of stroke. While blacks were more likely to be rehospitalized for more severe types of stroke in FY 2000 and FY 2001, this difference is not evident in later years. As with the index hospitalizations, follow-up period rehospitalizations were predominantly coded as emergent hospitalizations with the emergency room as the primary source of admission. In contrast to index hospitalizations, only from 37 to 45% of patients with follow-up rehospitalizations were discharged to home (Table 4). A significant proportion of discharges were to skilled nursing facilities or other facilities (most often rehabilitation hospitals). These trends reflect the greater severity of rehospitalizations and reflect the discharge patterns for ischemic stroke patients. While a very small percent of patients died during their index hospitalizations, from % of rehospitalized patients died.

9 Table 5 displays a proportional hazards model for time to rehospitalization for the 1999 cohort of Medicare beneficiaries hospitalized for TIA. Here older cohort members, women, blacks, Hispanics and patients receiving home health care after the index hospitalization had a higher risk of rehospitalization and patients discharged to skilled nursing or intermediate care facilities, inpatient hospitals or other postacute (rehabilitation) facilities had a lower risk of rehospitalization. Table 6 displays the survival trajectory post index discharge for the 1999 TIA cohort. It is broken out by whether or not patients were rehospitalized in FY Little difference in short-term post discharge survival is noted. In fact, survival rates are higher for those not rehospitalized during the first year post discharge. However, rehospitalized beneficiaries had lower survival rates from 2 to 5 years post-discharge. This group appears to be on a trajectory indicative of higher mortality rates than patients who were not rehospitalized. Table 7 displays a proportional hazards mortality model for mortality 5 years post discharge. The coefficient for rehospitalization indicates the effect of a FY 2000 rehospitalization on mortality. The coefficients obtained indicate older cohort members, blacks and those who were rehospitalized had an increased risk of mortality while women and Hispanics had a lower risk of mortality. Discussion: The results presented here indicate that rehospitalization of elderly patients hospitalized for TIA represent a small percentage of Medicare TIA patients in any specific follow-up year and this percentage decreases with time from initial discharge. However, the cumulative percent rehospitalized during the 5 year follow-up period was 18%. Thus, short-term examination of rehospitalization rates likely understate the long-term likelihood of rehospitalization for vascular conditions. Since over half of rehospitalizations were for ischemic or hemorrhagic strokes, they

10 produce a marked increase in the risk of institutionalization and mortality for this group of patients. The findings related to the effects of demographics on the likelihood of rehospitalization indicate that blacks and Hispanics have higher rehospitalization rates. The likelihood of more severe stroke for rehospitalized blacks in FY 2000 and FY 2001 merits further examination. The long term survival outcomes found here indicate that recurrent stroke reduces the likelihood of survival substantially compared to patients with their first vascular hospitalization. Samsa, et al., (1999) found similar results for Medicare beneficiaries hospitalized for stroke. Improvements in stroke prevention have been linked to improved survival (Fang and Alderman, 2001). Early initial treatment of TIA, preferably in an emergency room, is recommended for prevention of stroke in the immediate future (Gladstone, et al, 2004; Coull, et al, 2006; Rothwell, et al 2006; Sacco, et al, 2006). Several studies point out that TIAs are medical emergencies that require rapid intervention (Johnston and Hill, 2004; Giles and Rothwell 2005). Brain and neurovascular imaging appear to be promising diagnostic techniques (Johnston and Hill, 2004). One major advance has been the ability to identify which TIA patients have high early risk for stroke based on demographics, clinical features of the TIA and comorbidities (Rothwell, et al, 2006). This study has the following limitations. The 2 year look back period used to define the cohort may have been two short to be certain that only first ever cerebrovascular hospitalizations were captured.

11 REFERENCES Ayala, C., Croft, J., Greenlund, K., Keenan, N., Donehoo, R., Malarcher, A. and Mensah, G. (2002) "Sex Differences in US Mortality Rates for Stroke and Stroke Subtypes by Race/Ethnicity and Age, ," Stroke, 33, pp Bravata, D., Ho, S., Brass, L., Concato, J., Scinto, J., and Meehan, T. (2003) "Long-Term Mortality in Cerebrovascular Disease," Stroke, 34, pp Collins, T., Petersen, N., Menke, T., Souchek, J., Foster, W. and Ashton, C. (2003) "Short-term, Intermediate-term and Long-term Mortality in Patients Hospitalized for Stroke." Journal of Clinical Epidemiology, 168(4), pp Coull, A., Lovett, J., and Rothwell, P. (2004) Population Based Study of Early Risk of Stroke after Transient Ischaemic Attack or Minor Stroke: Implications for Public Education and Organization of Services, British Medical Journal, (328) pp Davis, H., Croft, J., Malarcher, A., Ayala, C., Antoine, T., Hyduk, A. and Mensah, G. (2003) "Public Health and Aging: Hospitalizations for Stroke Among Adults Aged > 65 Years." Morbidity and Mortality Weekly Report, 52 (25, June 27), pp Fang, J. and Alderman, M. (2001) "Trend of Stroke Hospitalization, United States, ," Stroke, 32, pp Giles, M., and Rothwell, P. (2005) The Need for Emergency Treatment of Transient Ischemic Attacks and Minor Stroke, Expert Reviews in Neurotheraputics, (5), pp Giles, M., and Rothwell, P. (2006) Prediction and Prevention of Stroke after Transient Ischemic Attacks in the Short and Long Term, Expert Reviews in Neurotheraputics, (6), pp Gillum, R. (1999) "Stroke Mortality in Blacks: Disturbing Trends," Stroke, 30, pp Gladstone, D., Kapral, M., Fang, J., Laupacis, A., and Tu, J. (2004) Management and Outcomes of Transient Ischemic Attacks in Ontario, Canadian Medical Association Journal, (170), pp Hardie, K., Hankey, G., Jamrozik, K., Broadhurst, R. and Anderson, C. (2003) Ten-Year Survival After First-Ever Stroke in the Perth Community Stroke Study. Stroke, (34) pp Hankey, G., Slattery, J., and Warlow, C. (1991) The Prognosis of Hospital-referred Transient Ischaemic Attacks. Journal of Neurology, Neurosurgery, and Psychiatry, (54) pp Hankey, G., Jamrozik, K., Broadhurst, R., Forbes, S., Burvill, P., Anderson, C. and Stewart-Wynne, E. (2000) Five-Year Survival After First-Ever Stroke and Related Prognostic Factors in the Perth Community Stroke Study. Stroke, (31) pp

12 Hankey, G. (2005) Redefining Risks after TIA and Minor Ischaemic Stroke:. Lancet, (365) pp Horner, R., Swanson, J., Bosworth, H., and Matchar, D. (2003) "Effects of Race and Poverty on the Process and Outcome of Inpatient Rehabilitation Services among Stroke Patients," Stroke, 34, pp Johnston, D. and Hill, M. (2004) The Patient with Transient Cerebral Ischemia: A Golden Opportunity for Stroke Prevention, Canadian Medical Association Journal, (170), pp Johnston, S., Sidney, S., Bernstein, A. and Gress, D. (2003) A Comparison of Risk Factors for Recurrent TIA and Stroke in Patients Diagnosed with TIA. Neurology, (60), pp Kennedy, B. (2005) "Does Race Predict Stroke Readmission? An Analysis Using the Truncated Negative Binomial Model," Journal of the National Medical Association, 97(5), pp Rothwell, P., Buchan, A., and Johnston, S. (2006) Recent Advances in Management of Transient Ischaemic Attacks and Minor Ischaemic Strokes, Lancet Neurology, (5), pp Rothwell, P., and Warlow, C. (2005) Timing of TIAs Preceding Stroke: Time Window for Prevention is Very Short, Neurology, (64), pp Sacco, R., Adams, R., Albers, G., Alberts, M., Benavente, O., Furie, K., Goldstein, L., Gorelick, P., Halperin, J., Harbaugh, R., Johnston, S., Katzan, I., Kelly-Hayes M., Kenton, E., Marks, M., Schwamm, L., and Tomsick, T. (2006) Guidelines for Prevention of Stroke in Patients with Ischemic Stroke or Transient Ischemic Attack, Stroke, (37), pp Samsa, G., Bian, J., Lipscomb, J. and Matchar, D. (1999) "Epidemiology of Recurrent Cerebral Infarction: A Medicare Claims-Based Comparison of First and Recurrent Strokes on 2-Year Survival and Costs," Stroke, 30, pp Verro, P. (2004) Early Risk of Stroke After Transient Ischemic Attack: Back to the Future, Canadian Medical Association Journal, (170), pp Van Wijk, I., Kappelle, L., Van Gijn, J., Kaudstaal, P., Franke, C., Vermuelen, M., Gorter, J., and Algra, A. (2005) Long-term Survival and Vascular Event Risk after Transient Ischaemic Attack or Minor Ischaemic Stroke: A Cohort Study. Lancet, (365) pp Williams, G. (2001) "Incidence and Characteristics of Total Stroke in the United States," BMC Neurology, 1(2), pp

13 Table 1 Demographic Statistics for the FY 1999 TIA Hospitalization Cohort Cases Percent Total 96, % Age Group 90 and Older 9, , , , , , Mean Age = 79.2 years of age. Sex Male 36, Female 59, Race White 84, Black 8, Hispanic 1, Other 2,

14 Table 2 Index Hospitalization Characteristics for the FY 1999 TIA Hospitalization Cohort Cases Percent Total 96, % Length of Stay = 3.47 Days. Total Covered Charges = $7,275 Admission Source Hospital SNF Other Facility Emergency Room 71, Other 23, Admission Type Emergent 64, Urgent 25, Elective 6, Other Discharge Destination Home 69, Hospital 1, SNF 10, ICF 2, Other Facility 2, Home Health 9, Died Other

15 Table 3 Demographic Statistics for Rehospitalized Patients FY FY 2004 FY 2000 FY 2001 FY 2002 FY 2003 FY 2004 Total 6,685 4,893 3,698 2,934 2,336 (100.0%) (100.0%) (100.0%) (100.0%) (100.0%) Age Group 90 and Older (12.6%) (13.9%) (14.9%) (14.5%) (16.0%) ,398 1, (20.9%) (20.6%) (22.3%) (21.2%) (23.5%) ,513 1, (22.6%) (24.8%) (26.2%) (25.5%) (24.4%) ,413 1, (21.1%) (21.2%) (20.0%) (22.6%) (22.4%) (14.2%) (13.8%) (12.4%) (13.5%) (12.1%) ( 8.6%) ( 5.8%) ( 4.3%) ( 2.8%) ( 1.6%) Mean Age (Years) Male 2,385 1,701 1,277 1, (35.7%) (34.8%) (34.5%) (35.5%) (36.4%) Female 4,300 3,192 2,421 1,891 1,486 (64.3%) (65.2%) (65.5%) (64.5%) (63.6%) Sex

16 Table 3 (Continued) Demographic Statistics for Rehospitalized Patients FY FY 2004 FY 2000 FY 2001 FY 2002 FY 2003 FY 2004 Race White 5,607 4,168 3,142 2,485 1,967 (85.4%) (85.2%) (85.0%) (84.7%) (84.2%) Black (10.5%) (10.5%) (10.7%) (11.1%) (11.7%) Hispanic ( 2.1%) ( 2.1%) ( 2.2%) ( 2.3%) ( 2.0%) Other ( 2.0%) ( 2.2%) ( 2.1%) ( 1.8%) ( 2.1%)

17 Table 4 Hospitalization Characteristics for FY FY 2004 Rehospitalizations FY 2000 FY 2001 FY 2002 FY 2003 FY 2004 Total 6,685 4,893 3,698 2,934 2,336 (100.0%) (100.0%) (100.0%) (100.0%) (100.0%) LOS Total Covered $10,444 $12,074 $13,662 $16,072 $16,473 Charges Principal Diagnosis Hemorrhage ( 6.2%) ( 5.7%) ( 6.4%) ( 8.5%) ( 6.7%) Precerebral Occlusion ( 2.1%) ( 2.4%) ( 2.6%) ( 2.8%) ( 3.3%) No Infarction Precerebral Occlusion ( 2.4%) ( 1.8%) ( 2.2%) ( 2.4%) ( 1.6%) With Infarction Cerebral Occlusion ( 0.9%) ( 1.0%) ( 0.8%) ( 1.3%) ( 1.6%) No Infarction Cerebral 1,887 1,413 1, Occlusion ( 28.2%) (28.9%) (31.4%) (33.3%) ( 34.3%) With Infarction Acute, but 1, Ill-defined (15.9%) (16.8%) (15.5%) (15.7%) (14.4%) All Major 3,727 2,772 2,179 1,878 1,446 Stroke (55.8%) (56.7%) (58.9%) (64.0%) (61.9%) TIA 2,958 2,121 1,519 1, (44.2%) (43.3%) (41.1%) (36.0%) (38.1%)

18 Table 4 (Continued) Hospitalization Characteristics for FY FY 2004 Rehospitalizations FY 2000 FY 2001 FY 2002 FY 2003 FY 2004 Admission Source Hospital ( 1.1%) ( 1.1%) ( 1.4%) ( 1.1%) ( 1.0%) SNF ( 1.2%) ( 1.2%) ( 1.1%) ( 0.9%) ( 0.9%) Other Facility ( 0.6%) ( 0.6%) ( 0.6%) ( 0.7%) ( 0.6%) Emergency 5,006 3,724 2,877 2,328 1,863 Room (74.9%) (76.1%) (77.8%) (79.4%) (79.8%) Other 1,489 1, (22.3%) (20.9%) (19.2%) (17.9%) (17.7%) Admission Type Emergent 4,625 3,488 2,668 2,165 1,771 (69.2%) (71.3%) (72.2%) (73.8%) (75.8%) Urgent 1,545 1, (23.1%) (22.0%) (22.3%) (20.0%) (18.3%) Elective ( 7.2%) ( 6.5%) ( 6.7%) ( 6.1%) ( 5.7%) Other ( 0.5%) ( 0.3%) ( 0.2%) ( 0.2%) ( 0.2%)

19 Table 4 (Continued) Hospitalization Characteristics for FY FY 2004 Rehospitalizations FY 2000 FY 2001 FY 2002 FY 2003 FY 2004 Discharge Destination Home 3,031 2,227 1,605 1, (45.3%) (45.5%) (43.4%) (40.4%) (37.2%) Hospital ( 1.8%) ( 2.2%) ( 2.3%) ( 1.3%) ( 1.1%) SNF 1,413 1, (21.4%) (22.3%) (21.0%) (23.0%) (24.3%) ICF ( 4.4%) ( 4.1%) ( 3.1%) ( 3.2%) ( 2.0%) Other Facility (10.3%) ( 9.6%) (11.7%) (11.3%) (11.9%) Home Health (10.2%) ( 9.6%) (10.1%) (10.3%) (14.9%) Died ( 6.1%) ( 5.8%) ( 6.9%) ( 8.1%) ( 6.2%) Other ( 0.6%) ( 0.5%) ( 1.5%) ( 2.0%) ( 2.6%)

20 Table 5 Proportional Hazards Model: Time to Rehospitalization Regression Standard Hazard Predictors Coefficient Error T Ratio Age Female Black Hispanic To Inpatient Hospital To Skilled Nursing Facility To Intermediate Care Facility To Other Postacute Facility Home Health Care N = 96,755, Likelihood Ratio X 2 = with 9 Degrees of Freedom

21 Table 6 Post-Index Discharge Survival for Cohort by Rehospitalization in FY 2000 At Group Discharge Days Days Years Years Years Years Years Rehospitalized 6,685 6,475 5,949 4,687 3,929 3,292 2,893 2,402 In FY 2000 (100.0%) (96.9%) (88.9%) (70.1%) (58.8%) (49.2%) (43.3%) (35.9%) Not Rehospitalized 89,825 82,758 77,849 69,397 61,419 54,084 49,122 43,156 In FY 2000 (99.7%) (91.9%) (86.4%) (77.1%) (68.2%) (60.1%) (61.5%) (47.9%) Total 96,510 89,233 83,798 74,084 65,348 57,376 52,015 45,558 (99.8%) (92.2%) (86.6%) (76.6%) (67.5%) (59.3%) (53.8%) (47.1%)

22 Table 7 Proportional Hazards 5-Year Mortality Model for Cohort Members Regression Standard Hazard Predictors Coefficient Error T Ratio Age Female Black Hispanic Rehospitalized in FY N = 96,755 Likelihood Ratio X 2 = 12,586.6 with 5 Degrees of Freedom