• Brystana G Kaufman, Emily C O'Brien, Sally C Stearns, Roland A Matsouaka, G Mark Holmes, Morris Weinberger, Lee H Schwamm, Eric E Smith, Gregg C Fonarow, Ying Xian, and Donald H Taylor.
• Department of Health Policy and Management, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
• J Am Geriatr Soc. 2019 Jul 1; 67 (7): 1402-1409.

ObjectivesPalliative care services have the potential to improve the quality of end-of-life care and reduce cost. Services such as the Medicare hospice benefit, however, are often underutilized among stroke patients with a poor prognosis. We tested the hypothesis that the Medicare Shared Savings Program (MSSP) is associated with increased hospice enrollment and inpatient comfort measures only among incident ischemic stroke patients with a high mortality risk.DesignA difference-in-differences design was used to compare outcomes before and after hospital participation in the MSSP for patients discharged from MSSP hospitals (N = 273) vs non-MSSP hospitals (N = 1490).SettingRecords from a national registry, Get with the Guidelines (GWTG)-Stroke, were linked to Medicare hospice claims (2010-2015).ParticipantsFee-for-service Medicare beneficiaries age 65 and older hospitalized for incident ischemic stroke at a GWTG-Stroke hospital from January 2010 to December 2014 (N = 324 959).InterventionDischarge from an MSSP hospital or beneficiary alignment with an MSSP Accountable Care Organization (ACO).MeasurementsHospice enrollment in the year following stroke.ResultsAmong patients with high mortality risk, ACO alignment was associated with a 16% increase in odds of hospice enrollment (adjusted odds ratio [OR] = 1.16; 95% confidence interval [CI] = 1.06-1.26), increasing the probability of hospice enrollment from 20% to 22%. In the low mortality risk group, discharge from an MSSP vs non-MSSP hospital was associated with a decrease in the predicted probability of inpatient comfort measures or discharge to hospice from 9% to 8% (OR = .82; CI = .74-.91), and ACO alignment was associated with reduced odds of a short stay (<7 days) (OR = .86; CI = .77-.96).ConclusionAmong ischemic stroke patients with severe stroke or indicators of high mortality risk, MSSP was associated with increased hospice enrollment. MSSP contract incentives may motivate improved end-of-life care among the subgroups most likely to benefit.© 2019 The American Geriatrics Society.

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