Kamakshi Lakshminarayan , Joe Larson, Candace Fuller for MS1371 WG

1. A Comprehensive Profile of Post-Discharge Clinical Care in Stroke Survivors: A Study of Current Practices KamakshiLakshminarayan, Joe Larson, Candace Fuller for MS1371 WG

2. MS1371 Objective Determine the range and variability of post-discharge outpatient clinical care for stroke patients discharged home • Intensity of care • Time to first physician visit • Frequency • Content • Secondary prevention (e.g. HTN Rx) • Prophylaxis (e.g. influenza vaccination)

3. Data • Data from the stroke validation paper • Comparison of Medicare Claims Versus Physician Adjudication for Identifying Stroke Outcomes in the WHI (Lakshminarayan et al. Stroke 2014; 45: 815-821) • WHI Yes/CMS Yes cell • All Stroke; Event Level Analysis • Total N = 478 + 478 = 956 (Training + Test data) • We will later look at: • Ischemic Stroke (N=369 + 383 = 752) • Hemorrhagic stroke (N = 82 + 70 = 152)

4. Variables • Variables pertaining to 3 time periods 1. Index stroke hospitalization 2. Pre-stroke period 3. Post-stroke period • Of these , the post-stroke period relies heavily on Medicare and is the most complex • Surprisingly the pre-stroke variables are non-trivial since they have to be pieced together from different forms • Luckily Joe had been piecing these together for other projects 4. Medications • Examined separately though we are mainly interested in their use after stroke; pre-stroke medications can be used to identify risk factors (such as DM)

5. INDEX STROKE HOSPITALIZATION VARIABLES

6. Index Stroke Hospitalization Variables • Most of variables from WHI Form 132, V 8.3 • Form 132 variables are • admission date • Functional Disability at discharge, • Stroke subtype (Ischemic, SAH, IPH, Other hemorrhage, Other stroke , • Stroke clinical presentation (OCSP), • Stroke mechanism (TOAST) • MedPAR • Admission & D/C dates; Discharge Destination • Interested in those discharged to acute rehab and home d/c

7. MedPAR File • MedPAR file became important early on • Need D/C destination (not in WHI) • Need D/C date – to start the clock for observation

8. MedPAR Details • Used Medicare linked data set (linked to denominator and MedPAR) and selected admit and discharge dates of the stroke hospitalization. All patients discharged home or after acute rehab will be selected. • - ADMSNDT=admission date • - DSCHRGDT= discharge date • -DSTNTNCD=discharge destination  (We will select only the underlined values in the next 2 slides)

9. MedPAR Discharge Destination - 1 • 01 = Discharged to home/self care (routine charge). • 02 = Discharged/transferred to other short term general hospital for inpatient care. • 03 = Discharged/transferred to skilled nursing facility (SNF) with Medicare certification in anticipation of covered skilled care -- (For hospitals with an approved swing bed arrangement, use Code 61 - swing bed. For reporting discharges/transfers to a non-certified SNF, the hospital must use Code 04 - ICF. • 04 = Discharged/transferred to intermediate care facility (ICF). • 05 = Discharged/transferred to another type of institution for inpatient care (including parts). NOTE: Effective 1/2005 psychiatric hospital or psychiatric distinct part unit of a hospital will no longer be identified by this code. New code is '65'. • 06 = Discharged/transferred to home care of organized home health service organization. • 07 = Left against medical advice or discontinued care. • 08 = Discharged/transferred to home under care of a home IV drug therapy provider. (discontinued effective 10/1/05) • 09 = Admitted as an inpatient to this hospital (effective 3/1/91). In situations where a patient is admitted before midnight of the third day following the day of an outpatient service, the out-patient services are considered inpatient. • 20 = Expired (did not recover – Christian Science patient). • 30 = Still patient.

10. Discharge Destination - 2 • 40 = Expired at home (hospice claims only) • 41 = Expired in a medical facility such as hospital, SNF, ICF, or freestanding hospice. (Hospice claims only) • 42 = Expired - place unknown (Hospice claims only) • 43 = Discharged/transferred to a federal hospital (eff. 10/1/03) • 50 = Hospice - home (eff. 10/96) • 51 = Hospice - medical facility (eff. 10/96) • 61 = Discharged/transferred within this institution to a hospital-based Medicare approved swing bed (eff. 9/01) • 62 = Discharged/transferred to an inpatient rehabilitation facility including distinct parts units of a hospital.(eff. 1/2002) • 63 = Discharged/transferred to a long term care hospitals. (eff. 1/2002) • 64 = Discharged/transferred to a nursing facility certified under Medicaid but not under Medicare (eff. 10/2002) • 65 = Discharged/Transferred to a psychiatric hospital or psychiatric distinct unit of a hospital (these types of hospitals were pulled from patient/discharge status code'05' and given their own code). (eff. 1/2005). • 66 = Discharged/transferred to a Critical Access Hospital (CAH) (eff. 1/1/06) institution for outpatient services as specified by the discharge plan of care(eff. 9/01) (discontinued effective 10/1/05) • 72 = Discharged/transferred/referred to this institution for outpatient services as specified by the discharge plan of care (eff. 9/01) (discontinued effective 10/1/05)

11. MedPAR Details • When does the clock start? • After acute stroke d/c (day 0) if they are going home • If they are going elsewhere, they are tracked and clock starts when they are discharged home finally • If d/c to Acute Rehabilitation then the clock starts when they leave rehab • We have to find the rehab stay in MedPAR using dates – patients enter rehab the same day or next day after the acute stroke d/c.

13. Final Sample Size for Study • N = 542 at the end of the MedPAR process • Ultimately ended up with N=541 participants – one person lost FFS when they left the hospital • Further restricted to those who were alive for 90 days and had FFS Parts A & B N = 512

14. POST-STROKE VARIABLES Primarily Medicare Based on 2 Files Carrier Outpatient

15. Carrier vs. Outpatient • Carrier file is about providers • Outpatient file is about hospital facility • cannot get the provider type; so very little about physicians • So one visit could be in both places outpatient and carrier files • These two files are not meant to connect • We can track things together via dates but dates will not be enough • will have to look provider types and procedure codes – since patients can get multiple services the same day • We started with initial exploratory work with Carrier Files

16. EXPLORATORY VARIABLES IN CARRIER • PLCSVC (first) • MTUS_IND – physician claims, office visits will be 3; there may be other (From MTUS_IND, we also have 20 ambulance claims, 55 anesthesia claims, and 7 blood claims) • FROM_DT , THRU_DT – these should match for ambulatory visits • HCFASPCL • http://www.resdac.org/sites/resdac.org/files/HCFA%20Provider%20Specialty%20Table.txt