The effect of cuts in reimbursement on stroke outcome: a nationwide population-based study during the period 1998 to 2007.

BACKGROUND AND PURPOSE As healthcare costs keep rising, cuts in reimbursement such as the Balanced Budget Act in the United States or global budgeting have become the key to healthcare reform efforts. Limited information is available, however, concerning whether reimbursement cuts are associated with changes in stroke outcomes. The objective of this study is to determine whether 30-day mortality rates for patients with ischemic stroke changed under increased financial strain from global budgeting in Taiwan. METHODS We analyzed all 258 167 patients with ischemic stroke admitted to general acute care hospitals in Taiwan over the period 1998 to 2007 through Taiwan's National Health Insurance Research Database. Multilevel logistic regression analysis was used to examine whether 30-day stroke mortality rates varied after the implementation of hospital global budgeting since July 2002 adjusted for patient, physician, and hospital characteristics. RESULTS The magnitude of payment reduction on overall hospital net revenues was between 4.3% and 10.0%. The 30-day mortality rates for patients with ischemic stroke in Taiwan increased after the implementation of hospital global budgeting after adjustment for patient gender and age, comorbidities, surgery, physician age and volume, specialty, hospital volume, ownership, accreditation level, bed size, geographic location, competition, and trend. CONCLUSIONS The mortality rate of patients with stroke rose under increased financial strain from cuts in reimbursement. Therefore, stroke outcomes are more likely to be affected by hospital financial pressures. It is imperative to monitor stroke outcomes and develop strategies to maintain levels of stroke care as cuts in reimbursement are adopted.