Drugs & Aging

, Volume 23, Issue 1, pp 61–69 | Cite as

Did the Introduction of a Prospective Payment System for Nursing Home Stays Reduce the Likelihood of Pharmacological Management of Secondary Ischaemic Stroke?

Original Research Article



Since 1998, a prospective payment system (PPS) for Medicare services provided by nursing homes in the US has been in operation. Concerns have been expressed that the PPS may affect the quality of care delivered to residents. This study evaluates the impact of the PPS on pharmacological secondary ischaemic stroke prevention in nursing homes.

Study design

The nationally mandated Minimum Data Set and Online Survey Certification and Automated Record data system from 1997 and 2000 for four states were used. We conducted a quasi-experimental study comparing the pharmacological treatment rates for secondary stroke prevention in the pre-PPS period (1997) with those in the post-PPS period (2000) in residents who experienced an ischaemic stroke within 6 months (n1997 = 5008; n2000 = 5243) of living in nursing facilities (n1997 = 1226; n2000 = 1092) in Kansas, Maine, Mississippi or Ohio. The sample was stratified according to recommendations for use of warfarin. Logistic regression models adjusting for clustering effects of residents residing in homes using generalised estimating equations provided estimates of the PPS effect on use of antiplatelets and the use of warfarin.


The unadjusted proportion of use of pharmacological agents for the secondary prevention of stroke was similar for warfarin in both time periods and increased for antiplatelets in 2000. Relative to the pre-PPS era, the likelihood of use of antiplatelets increased in the post-PPS era (adjusted odds ratio 1.26; 95% CI 1.15, 1.38); there was no effect on the use of warfarin.


Although the lack of a PPS effect on pharmacological management of secondary ischaemic stroke is encouraging, there is still room for improvement in overall stroke management.



Professor Hughes is currently being supported by a National Primary Care Career Scientist Award from the Research and Development Office, Northern Ireland.

The authors have no conflicts of interest that are directly relevant to the content of this study.


  1. 1.
    Hughes CM, Lapane KL. The drive for quality care in US nursing homes in the era of the prospective payment system. Drugs Aging 2002; 19: 623–31PubMedCrossRefGoogle Scholar
  2. 2.
    Health Care Financing Administration (HCFA). Medicare program; prospective payment system and consolidated billing for skilled nursing facilities: update. Health and Human Services: Final Rule. Fed Regist 2000; 65: 46770–96Google Scholar
  3. 3.
    Department of Health and Human Services. Office of Inspector General: early effects of the prospective payment system on access to skilled nursing facilities; August 1999. OEI-02-99-00400 [online]. Available from URL: http://www.dhhs.gov/progorg/oei [Accessed 2004 Oct 15]
  4. 4.
    Department of Health and Human Services. Office of Inspector General: early effects of the prospective payment system on access to skilled nursing facilities. Nursing Home Administrators’ Perspective; October 1999. OEI-02-99-00401 [online]. Available from URL: http://www.dhhs.gov/progorg/oei [Accessed 2004 Oct 15]
  5. 5.
    Leibson CL, Ransom JE, Brown RD, et al. Stroke-attributable nursing home use: a population-based study. Neurology 1998; 51: 163–8PubMedCrossRefGoogle Scholar
  6. 6.
    Quilliam BJ, Lapane KL. Clinical correlates and drug treatment of residents with stroke in long-term care. Stroke 2001; 32: 1385–93PubMedCrossRefGoogle Scholar
  7. 7.
    Christian JB, Lapane KL, Toppa RS. Racial disparities in receipt of secondary stroke prevention agents in US nursing homes. Stroke 2003; 34: 2693–7PubMedCrossRefGoogle Scholar
  8. 8.
    Gurwitz JH, Monette J, Rochon PA, et al. Atrial fibrillation and stroke prevention with warfarin in the long-term care setting. Arch Intern Med 1997; 157: 978–84PubMedCrossRefGoogle Scholar
  9. 9.
    McCormick D, Gurwitz JH, Goldberg RJ, et al. Prevalence and quality of warfarin use for patients with atrial fibrillation in the long-term care setting. Arch Intern Med 2001; 161: 2458–63PubMedCrossRefGoogle Scholar
  10. 10.
    Gambassi G, Landi F, Peng L, et al. Validity of diagnostic and drug data on standardized nursing home resident assessments: potential for geriatric pharmaco-epidemiology. Med Care 1998; 36: 167–9PubMedCrossRefGoogle Scholar
  11. 11.
    Minimum Data Set Plus training manual. Natick (MA): Eliot Press, 1991Google Scholar
  12. 12.
    Morris JN, Fries BE, Mehr DR, et al. MDS cognitive performance scale. J Gerontol 1994; 49: M174–82PubMedCrossRefGoogle Scholar
  13. 13.
    Mor V, Branco K, Fleishman F, et al. The structure of social engagement among nursing home residents. J Gerontol 1994; 50B: P1–8Google Scholar
  14. 14.
    Hartmaier SL, Sloane PD, Guess HA, et al. Validation of the Minimum Data Set Cognitive Performance Scale: agreement with the Mini-Mental State Examination. J Gerontol 1995; 50A: Ml28–33Google Scholar
  15. 15.
    Stahl DA. The nuts and bolts of prospective payment. Nurs Manage 1998; 29: 20–3PubMedGoogle Scholar
  16. 16.
    Grimaldi P. New skilled nursing facility payment scheme boosts Medicare risk. J Health Care Financ 1999; 25: 1–9Google Scholar
  17. 17.
    Benesch C, Witter Jr DM, Wilder AL, et al. Inaccuracy of the International Classification of Diseases (ICD-9-CM) in identifying the diagnosis of ischemic cerebrovascular disease. Neurology 1997; 49: 660–4PubMedCrossRefGoogle Scholar
  18. 18.
    Goldstein LB. Accuracy of ICD-9-CM coding for the identification of patients with acute ischemic stroke: effect of modifier codes. Stroke 1998; 29: 1602–4PubMedCrossRefGoogle Scholar
  19. 19.
    Leibson CL, Naessens JM, Brown RD, et al. Accuracy of hospital discharge abstracts for identifying stroke. Stroke 1994; 25: 2348–55PubMedCrossRefGoogle Scholar
  20. 20.
    SAS Institute Inc. SAS/STAT Software: changes and enhancement through release 6.12 (ISBN 1-55544-873-9). Cary NC): SAS Institute Inc., 1997Google Scholar
  21. 21.
    Greenland S, Rothman KJ. Concepts of interaction. In: Rothman KJ, Greenland S, editors. Modern Epidemiology. 2nd ed. Philadelphia (PA): Lippincott-Raven, 1998: 329–43Google Scholar
  22. 22.
    CMS. Centers for Medicaid and Medicare [online]. Available from URL: http://www.CMS.gov [Accessed 2004 Oct 12]
  23. 23.
    Petrisek AC, Mor V. Hospice in nursing homes: a facility-level analysis of the distribution of hospice beneficiaries. Gerontologist 1999; 39: 279–90PubMedCrossRefGoogle Scholar
  24. 24.
    Strahan G. An overview of nursing homes and their current residents: data from the 1995 National Nursing Homes Survey. Advance data from the Vital and Health Statistics, no. 280. Hyattsville (MD): National Center for Health Statistics, 1997Google Scholar
  25. 25.
    Lapane KL, Hughes CM. An evaluation of the impact of the Prospective Payment System on antidepressant use in nursing home residents. Med Care 2004; 42: 48–58PubMedCrossRefGoogle Scholar
  26. 26.
    Center for Health Systems Research and Analysis. Facility Guide for the Nursing Home Quality Indicators, 1999. National Data Systems, University of Wisconsin, Madison [online]. Available from URL: http//www.cms.hhs.gov/medicaid/ltcsp/manual.pdf [Accessed 2003 Dec 22]Google Scholar
  27. 27.
    Angelelli J, Gifford D, Intrator O, et al. Access to postacute nursing home care before and after the BBA. Health Affairs 2002; 21: 254–64PubMedCrossRefGoogle Scholar
  28. 28.
    Konetza RT, Yi D, Norton EC, et al. Effects of Medicare payment changes on nursing home staffing and deficiencies. Health Serv Res 2004; 39: 463–87CrossRefGoogle Scholar
  29. 29.
    United States General Accounting Office. Skilled nursing facilities: Medicare payment changes require provider adjustments but maintain access. Report to the Chairman and Ranking Minority Member, Committee on Finance, US Senate and the Chairman, Special Committee on Aging, US Senate: Washington DC, December 1999. GAO/HEHS-00-23 [online]. Available from URL: http://www.gao.gov [Accessed 2004 Sep 19]Google Scholar
  30. 30.
    Skilled Nursing Facilities. Prospective payment system and consolidated billing: chapter III. History and Part A requirements [online]. Available from URL: http://www.cms.gov/medlearn [Accessed 2004 Oct 12]
  31. 31.
    BMA/RPSGB. British National Formulary 2004, No. 48. London: British Medical Association and the Royal Pharmaceutical Society of Great Britain, 2004Google Scholar
  32. 32.
    Zinn JS, Mor V, Intrator O, et al. The impact of the prospective payment system for skilled nursing facilities on therapy service provision: a transaction cost approach. Health Serv Res 2003; 38: 1467–85PubMedCrossRefGoogle Scholar
  33. 33.
    Mor V, Zinn J, Angelelli J, et al. Driven to tiers: socioeconomic and racial disparities in the quality of nursing home care. Milbank Q 2004; 82: 227–56PubMedCrossRefGoogle Scholar
  34. 34.
    Monette J, Gurwitz JH, Rochon PA, et al. Physician attitudes concerning warfarin for stroke prevention in atrial fibrillation: results of a survey of long-term care practitioners. J Am Geriatr Soc 1997; 45: 1060–5PubMedGoogle Scholar
  35. 35.
    Quilliam BJ, Lapane KL, Eaton CB, et al. Effect of antiplatelet and anticoagulant agents on risk of hospitalization for bleeding among a population of elderly nursing home stroke survivors. Stroke 2001; 32: 2299–304PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2006

Authors and Affiliations

  1. 1.Department of Community HealthBrown Medical SchoolProvidenceUSA
  2. 2.School of PharmacyThe Queen’s University of BelfastBelfastNorthern Ireland

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