Outcomes after ischemic stroke for dual-eligible Medicare-Medicaid beneficiaries in the United States

BACKGROUND: Medicaid serves as a safety net for low-income US Medicare beneficiaries with limited assets. Approximately 7.7 million Americans aged ≥65 years rely on a combination of Medicare and Medicaid to obtain critical medical services, yet little is known about whether these patients have worse outcomes after stroke than patients with Medicare alone. We compared geographic patterns in dual Medicare-Medicaid eligibility and ischemic stroke hospitalizations and examined whether these dual-eligible beneficiaries had worse post-stroke outcomes than those with Medicare alone. METHODS: We identified fee-for-service Medicare beneficiaries aged ≥65 years who were discharged from US acute-care hospitals with a principal diagnosis of ischemic stroke in 2014. Medicare beneficiaries with ≥1 month of Medicaid coverage were considered dual eligible. We mapped risk-standardized stroke hospitalization rates and percentages of beneficiaries with dual eligibility. Mixed models and Cox regression were used to evaluate relationships between dual-eligible status and outcomes up to 1 year after stroke, adjusting for demographic and clinical factors. RESULTS: At the national level, 12.5% of beneficiaries were dual eligible. Dual-eligible rates were highest in Maine, Alaska, and the southern half of the United States, whereas stroke hospitalization rates were highest in the South and parts of the Midwest (Pearson’s r = 0.469, p<0.001). Among 254,902 patients hospitalized for stroke, 17.4% were dual eligible. In adjusted analyses, dual-eligible patients had greater risk of all-cause readmission within 30 days (hazard ratio 1.06, 95% confidence interval [CI] 1.03–1.09) and 1 year (hazard ratio 1.03, 95% CI 1.02–1.05) and had greater odds of death within 1 year (odds ratio 1.20, 95% CI 1.17–1.23) when compared with Medicare-only patients; there was no difference in in-hospital or 30-day mortality. CONCLUSION: Dual-eligible stroke patients had higher readmissions and long-term mortality than other patients, even after comorbidity adjustment. A better understanding of the factors contributing to these poorer outcomes is needed.