Mark E. Totten

How Much is Post-Acute Care Use Affected by its Availability?

OBJECTIVE To assess the relative impact of clinical factors versus nonclinical factors-such as postacute care (PAC) supply-in determining whether patients receive care from skilled nursing facilities (SNFs) or inpatient rehabilitation facilities (IRFs) after discharge from acute care. DATA SOURCES AND STUDY SETTING Medicare acute hospital, IRF, and SNF claims provided data on PAC choices; predictors of site of PAC chosen were generated from Medicare claims, provider of services, enrollment file, and Area Resource File data. STUDY DESIGN We used multinomial logit models to predict PAC use by elderly patients after hospitalizations for stroke, hip fractures, or lower extremity joint replacements. DATA COLLECTION/EXTRACTION METHODS A file was constructed linking acute and postacute utilization data for all medicare patients hospitalized in 1999. PRINCIPAL FINDINGS PAC availability is a more powerful predictor of PAC use than the clinical characteristics in many of our models. The effects of distance to providers and supply of providers are particularly clear in the choice between IRF and SNF care. The farther away the nearest IRF is, and the closer the nearest SNF is, the less likely a patient is to go to an IRF. Similarly, the fewer IRFs, and the more SNFs, there are in the patients area the less likely the patient is to go to an IRF. In addition, if the hospital from which the patient is discharged has a related IRF or a related SNF the patient is more likely to go there. CONCLUSIONS We find that the availability of PAC is a major determinant of whether patients use such care and which type of PAC facility they use. Further research is needed in order to evaluate whether these findings indicate that a greater supply of PAC leads to both higher use of institutional care and better outcomes-or whether it leads to unwarranted expenditures of resources and delays in returning patients to their homes.

The effect of deployment on first‐ and second‐term re‐enlistment in the US active duty force

Why should deployment affect re‐enlistment? In our model, members enter the military with naïve beliefs about deployment and use actual deployment experience to update their beliefs and revise their expected utility of re‐enlisting. Empirically, re‐enlistment is related to the type and number of deployments, consistent with the learning model. Non‐hostile deployment increases first‐term re‐enlistment but hostile deployment has little effect except for the Army, where the effect is positive. Both types increase second‐term re‐enlistment. Interestingly, first‐term members with dependants tend to respond to deployment like second‐term members. In addition, deployment acts directly to affect re‐enlistment, not indirectly through time to promotion.