Impact of care coordination on 30-day readmission, mortality, and costs for heart failure.

OBJECTIVES: Although coordination of care has become the main focus of health care reform efforts to improve outcomes and decrease costs, limited information is available concerning the impact of care coordination on 30-day outcomes and costs. We used nationwide, population-based data to examine the influence of care coordination on 30-day readmission, mortality, and costs for heart failure (HF). STUDY DESIGN: We analyzed 20,713 patients with HF 18 years or older discharged from hospitals in 2016 using Taiwan's National Health Insurance Research Database. The coordination of care among a patient's outpatient physicians was measured with care density. METHODS: Multilevel regression models were used after adjustment for patient and hospital characteristics to explore the impact of care density on 30-day readmission, mortality, and costs. RESULTS: Patients with high care coordination had lower odds of 30-day readmission (OR, 0.90; 95% CI, 0.82-0.98) and mortality (OR, 0.83; 95% CI, 0.70-0.99) and lower costs (cost ratio [CR], 0.84; 95% CI, 0.79-0.90) compared with those with low care coordination. Patients with medium care coordination had lower costs (CR, 0.92; 95% CI, 0.86-0.98) than those with low care coordination. CONCLUSIONS: High care coordination is associated with decreased 30-day readmission, mortality, and costs for HF. Enhancing coordination of care has the potential to increase the value of care. It is important to monitor coordination of care and develop strategies to maintain high levels of care coordination for HF.

Associations of continuity and coordination of care with outcomes and costs after discharge among patients with heart failure: A nationwide population-based study.

BACKGROUND: Although continuity and coordination of care have received increased attention as important ways to improve outcomes and decrease costs, limited information is available concerning the effects of "care continuity" and "care coordination" on mortality and costs. We used nationwide population-based data from Taiwan to explore the effects of care continuity and coordination on mortality and costs for heart failure. METHODS: We analyzed all 18,991 heart failure patients 18 years of age or older and discharged from hospitals in 2016 using Taiwan's National Health Insurance claims data. Cox proportional hazard and multiple linear regression models were used, after adjustment for patient characteristics, to explore the relative impacts of the continuity of care (COC) index and care density on 1-year mortality and costs. RESULTS: Higher COC index was associated with lower mortality (low vs. medium: hazard ratio [HR], 1.59; 95% confidence interval [CI], 1.47-1.71; high vs. medium: HR, 0.66; 95% CI, 0.61-0.72) and costs (low vs. medium: cost ratio [CR], 1.11; 95% CI, 1.07-1.16; high vs. medium: CR, 0.84; 95% CI, 0.81-0.88). Low care density was associated with higher mortality (low vs. medium: HR, 1.12; 95% CI, 1.04-1.20). Higher care density was associated with lower costs (low vs. medium: CR, 1.14; 95% CI, 1.10-1.18; high vs. medium: CR, 0.76; 95% CI, 0.73-0.79). CONCLUSIONS: Low care continuity and coordination are associated with higher 1-year post-discharge mortality and costs. Facilitating care continuity and coordination may be an important strategy for improving value-based care for heart failure.

Optimal surgeon and hospital volume thresholds to reduce mortality and length of stay for CABG.

OBJECTIVE: We used nationwide population-based data to identify optimal hospital and surgeon volume thresholds and to discover the effects of these volume thresholds on operative mortality and length of stay (LOS) for coronary artery bypass surgery (CABG). DESIGN: Retrospective cohort study. SETTING: General acute care hospitals throughout Taiwan. PARTICIPANTS: A total of 12,892 CABG patients admitted between 2011 and 2015 were extracted from Taiwan National Health Insurance claims data. MAIN OUTCOME MEASURES: Operative mortality and LOS. Restricted cubic splines were applied to discover the optimal hospital and surgeon volume thresholds needed to reduce operative mortality. Generalized estimating equation regression modeling, Cox proportional-hazards modeling and instrumental variables analysis were employed to examine the effects of hospital and surgeon volume thresholds on the operative mortality and LOS. RESULTS: The volume thresholds for hospitals and surgeons were 55 cases and 5 cases per year, respectively. Patients who underwent CABG from hospitals that did not reach the volume threshold had higher operative mortality than those who received CABG from hospitals that did reach the volume threshold. Patients who underwent CABG with surgeons who did not reach the volume threshold had higher operative mortality and LOS than those who underwent CABG with surgeons who did reach the volume threshold. CONCLUSIONS: This is the first study to identify the optimal hospital and surgeon volume thresholds for reducing operative mortality and LOS. This supports policies regionalizing CABG at high-volume hospitals. Identifying volume thresholds could help patients, providers, and policymakers provide optimal care.

Association of antidiabetic therapies with lower extremity amputation, mortality and healthcare cost from a nationwide retrospective cohort study in Taiwan.

We compared risks of clinical outcomes, mortality and healthcare costs among new users of different classes of anti-diabetic medications. This is a population-based, retrospective, new-user design cohort study using the Taiwan National Health Insurance Database between May 2, 2015 and September 30, 2017. An individual was assigned to a medication group based on the first anti-diabetic prescription on or after May 1, 2016: SGLT-2 inhibitors, DPP-4 inhibitors, GLP-1 agonists or older agents (metformin, etc.). Clinical outcomes included lower extremity amputation, peripheral vascular disease, critical limb ischemia, osteomyelitis, and ulcer. We built three Cox proportional hazards models for clinical outcomes and mortality, and three regression models with a log-link function and gamma distribution for healthcare costs, all with propensity-score weighting and covariates. We identified 1,222,436 eligible individuals. After adjustment, new users of SGLT-2 inhibitors were associated with 73% lower mortality compared to those of DPP-4 inhibitors or users of older agents, while 36% lower total costs against those of GLP-1 agonists. However, there was no statistically significant difference in the risk of lower extremity amputation across medication groups. Our study suggested that SGLT-2 inhibitors is associated with lower mortality compared to DPP 4 inhibitors and lower costs compared to GLP-1 agonists.

External Validation of and Factors Associated with the Overuse Index: a Nationwide Population-Based Study from Taiwan.

BACKGROUND: The Overuse Index (OI), previously called the Johns Hopkins Overuse Index, is developed and validated as a composite measure of systematic overuse/low-value care using United States claims data. However, no information is available concerning whether the external validation of the OI is sustained, especially for international application. Moreover, little is known about which supply and demand factors are associated with the OI. OBJECTIVE: We used nationwide population-based data from Taiwan to externally validate the OI and to examine the association of regional healthcare resources and socioeconomic factors with the OI. DESIGN AND PARTICIPANTS: We analyzed 1,994,636 beneficiaries randomly selected from all people enrolled in the Taiwan National Health Insurance in 2013. MAIN MEASURES: The OI was calculated for 2013 to 2015 for each of 50 medical regions. Spearman correlation analysis was applied to examine the association of the OI with total medical costs per capita and mortality rate. Generalized estimating equation linear regression analysis was conducted to examine the association of regional healthcare resources (number of hospital beds per 1000 population, number of physicians per 1000 population, and proportion of primary care physicians [PCPs]) and socioeconomic factors (proportion of low-income people and proportion of population aged 20 and older without a high school diploma) with the OI. RESULTS: Higher scores of the OI were associated with higher total medical costs per capita (ρ = 0.48, P < 0.001) and not associated with total mortality (ρ = - 0.01, P = 0.882). Higher proportions of PCPs and higher proportions of low-income people were associated with lower scores of the OI (ß = - 0.022, P = 0.016 and ß = - 0.224, P < 0.001, respectively). CONCLUSIONS: Our study supported the external validation of the OI by demonstrating a similar association within a universal healthcare system, and it showed the association of a higher proportion of PCPs and a higher proportion of low-income people with less overuse/low-value care.

Comparison of the cost of illness of primary liver cancer between Japan and Taiwan.

BACKGROUND: Primary liver cancer (PLC) is the fifth and second leading cause of death in Japan and Taiwan, respectively. The aim of this study was to compare the economic burden of PLC between the two countries using the cost of illness (COI) method and identify the key factors causing the different trends in the economic burdens of PLC. MATERIALS AND METHODS: We calculated the COI every 3 years using governmental statistics of both countries (1996-2014 data for Japan and 2002-2014 data for Taiwan). The COI was calculated by summing the direct costs, morbidity costs, and mortality costs. We compared the COIs of PLC in both countries at the USD-based cost. The average exchange rate during the targeted years was used to remove the impact of foreign exchange volatility. RESULTS: From 1996 to 2014, the COI exhibited downward and upward trends in Japan and Taiwan, respectively. In Japan, the COI in 2014 was 0.70 times the value in 1996, and in Taiwan, the COI in 2014 was 1.16 times greater than that in 1996. The mortality cost was the greatest contributor in both countries and had the largest contribution ratio to the COI increase in Japan. However, the direct cost in Taiwan had the largest contribution ratio to the COI decrease. CONCLUSIONS: To date, the COI of PLC in Japan has continuously decreased, whereas that in Taiwan has increased. Previous health policies and technological developments are thought to have accelerated the COI decrease in Japan and are expected to change the trend of COI of PLC, even in Taiwan.

Early Do-Not-Resuscitate Directives Decrease Invasive Procedures and Health Care Expenses During the Final Hospitalization of Life of COPD Patients.

CONTEXT: Nearly 70% of do-not-resuscitate (DNR) directives for chronic obstructive pulmonary disease (COPD) patients are established during their terminal hospitalization. Whether patient use of end-of-life resources differs between early and late establishment of a DNR is unknown. OBJECTIVES: The objective of this study was to compare end-of-life resource use between patients according to DNR directive status: no DNR, early DNR (EDNR) (established before terminal hospitalization), and late DNR (LDNR) (established during terminal hospitalization). METHODS: Electronic health records from all COPD decedents in a teaching hospital in Taiwan were analyzed retrospectively with respect to medical resource use during the last year of life and medical expenditures during the last hospitalization. Multivariate linear regression analysis was used to determine independent predictors of cost. RESULTS: Of the 361 COPD patients enrolled, 318 (88.1%) died with a DNR directive, 31.4% of which were EDNR. COPD decedents with EDNR were less likely to be admitted to intensive care units (12.0%, 55.5%, and 60.5% for EDNR, LDNR, and no DNR, respectively), had lower total medical expenditures, and were less likely to undergo invasive mechanical ventilator support during their terminal hospitalization. The average total medical cost during the last hospitalization was nearly twofold greater for LDNR than for EDNR decedents. Multivariate linear regression analysis revealed that nearly 60% of medical expenses incurred were significantly attributable to no EDNR, younger age, longer length of hospital stay, and more comorbidities. CONCLUSION: Although 88% of COPD decedents died with a DNR directive, 70% of these directives were established late. LDNR results in lower quality of care and greater intensive care resource use in end-of-life COPD patients.

Optimal Hospital and Surgeon Volume Thresholds to Improve 30-Day Readmission Rates, Costs, and Length of Stay for Total Hip Replacement.

BACKGROUND: Little is known about whether there are optimal hospital and surgeon volume thresholds to reduce readmission, costs, and length of stay (LOS) for total hip replacement (THR). Nationwide population-based data were applied to identify the optimal hospital and surgeon volume thresholds and to discover the effects of these volume thresholds on 30-day unplanned readmission, costs and LOS for THR. METHODS: A total of 6367 patients identified through Taiwan's National Health Insurance Research Database received THR in 2012. Restricted cubic splines were used to identify the optimal hospital and surgeon volume needed to decrease the risk of 30-day unplanned readmission. Multilevel regression modeling and propensity score weighting were used to examine the impact of hospital and surgeon volume thresholds on 30-day unplanned readmission, costs, and LOS, after adjusting for patient, surgeon, and hospital characteristics. RESULTS: The volume thresholds for hospitals and surgeons were 65 cases and 15 cases a year, respectively. The overall mean LOS was 7.3 ± 4.3 days. Patients who received THR from surgeons who did not reach the volume threshold had higher 30-day unplanned readmission rates, costs, and LOS than those who received THR from surgeons who reached the volume threshold. CONCLUSION: This is the first study to identify the surgeon volume threshold that can reduce 30-day unplanned readmission rates, costs, and LOS for THR. However, the results from Taiwan may not be applicable to other parts of the world. Identifying the threshold could help patients, providers, and policymakers to make decisions regarding optimal delivery of THR.

Impact of bundled payments on hip fracture outcomes: a nationwide population-based study.

OBJECTIVE: Establishing one price for all bundled services for a particular illness, which has become the key to healthcare reform efforts, is designed to encourage health professionals to coordinate their care for patients. Limited information is available, however, concerning whether bundled payments are associated with changes in patient outcomes. Nationwide longitudinal population-based data were used to examine the effect of bundled payments on hip fracture outcomes. DESIGN: An interrupted time series design with a comparison group. SETTING: General acute care hospitals throughout Taiwan. PARTICIPANTS: A total of 178 586 hip fracture patients admitted over the period 2007-12 identified from the Taiwan's National Health Insurance Research Database. INTERVENTION: Bundled payments for hip fractures were implemented in Taiwan in January 2010. MAIN OUTCOME MEASURES: The 30-day unplanned readmission and postdischarge mortality. Segmented generalized estimating equation regression models were used after adjustment for trends, patient, physician and hospital characteristics to assess the effect of bundled payments on 30-day outcomes for hip fracture compared with a reference condition. RESULTS: The 30-day unplanned readmission rate for hip fracture showed a relative decreasing trend after the implementation of bundled payments compared with the trend before the implementation relative to that of the reference condition. CONCLUSIONS: This finding might imply that the implementation of bundled payments encourages health professionals to coordinate their care, leading to reduced readmission for hip fracture.

Can Hospital Competition Really Affect Hospital Behavior or Not? An Empirical Study of Different Competition Measures Comparison in Taiwan.

Different approaches to measure the hospital competition index might lead to inconsistent results of the effects of hospital competition on innovation adoption. The purpose of this study is to adopt a different approach to define market area and measure the level of competition to examine whether hospital competition has a positive effect on hospital behavior, taking quality indicator projects participation as an example. A total of 238 hospitals located in Taipei, Taichung, and Kaohsiung were recruited in this study. Competition index was used as the independent variable, and participation lists of Taiwan Clinical Performance Indicator and Taiwan Healthcare Indicator Series in 2012 were used as dependent variables. All data used in this study were retrieved from the 2012 national hospital profiles and the participation list of the 2 quality indicator projects in 2012; these profiles are issued by the Taiwan Ministry of Health and Welfare annually. Geopolitical boundaries and 4 kinds of fixed radiuses were used to define market area. Herfindahl-Hirschman Index and hospital density were used to measure the level of competition. A total of 12 competition indices were produced in this study by employing the geographic information system, while max-rescaled R2 was used to evaluate and compare the models on goodness of fit. The results show that the effects of hospital competition on quality indicator projects participation were varied, which mean different indicators for market competition might reveal different conclusions. Furthermore, this study also found the Herfindahl-Hirschman Index at 5-km radius was the optimum competition index.

Relationship between Early Physician Follow-Up and 30-Day Readmission after Acute Myocardial Infarction and Heart Failure.

BACKGROUND: Thirty-day readmission rates after acute myocardial infarction (AMI) and heart failure are important patient outcome metrics. Early post-discharge physician follow-up has been promoted as a method of reducing 30-day readmission rates. However, the relationships between early post-discharge follow-up and 30-day readmission for AMI and heart failure are inconclusive. We used nationwide population-based data to examine associations between 7-day physician follow-up and 30-day readmission, and further associations of 7-day same physician (during the index hospitalization and at follow-up) and cardiologist follow-up with 30-day readmission for non-ST-segment-elevation myocardial infarction (NSTEMI) or heart failure. METHODS: We analyzed all patients 18 years or older with NSTEMI and heart failure and discharged from hospitals in 2010 in Taiwan through Taiwan's National Health Insurance Research Database. Cox proportional hazard models with robust sandwich variance estimates and propensity score weighting were performed after adjustment for patient and hospital characteristics to test associations between 7-day physician follow-up and 30-day readmission. RESULTS: The study population for NSTEMI and heart failure included 5,008 and 13,577 patients, respectively. Early physician follow-up was associated with a lower hazard ratio of readmission compared with no early physician follow-up for patients with NSTEMI (hazard ratio [HR], 0.47; 95% confidence interval [CI], 0.39-0.57), and for patients with heart failure (HR, 0.54; 95% CI, 0.48-0.60). Same physician follow-up was associated with a reduced hazard ratio of readmission compared with different physician follow-up for patients with NSTEMI (HR, 0.56; 95% CI, 0.48-0.65), and for patients with heart failure (HR, 0.69; 95% CI, 0.62-0.76). CONCLUSIONS: For each condition, patients who have an outpatient visit with a physician within 7 days of discharge have a lower risk of 30-day readmission. Moreover, patients who have an outpatient visit with the same physician within 7 days of discharge have a much lower risk of 30-day readmission.

Impact of universal health coverage on urban-rural inequity in psychiatric service utilisation for patients with first admission for psychosis: a 10-year nationwide population-based study in Taiwan.

OBJECTIVE: To examine the disparities in psychiatric service utilisation over a 10-year period for patients with first admission for psychosis in relation to urban-rural residence following the implementation of universal health coverage in Taiwan. DESIGN: Population-based retrospective cohort study. SETTING: Taiwan's National Health Insurance Research Database, which has a population coverage rate of over 99% and contains all medical claim records of a nationwide cohort of patients with at least one psychiatric admission between 1996 and 2007. PARTICIPANTS: 69,690 patients aged 15-59 years with first admission between 1998 and 2007 for any psychotic disorder. MAIN EXPOSURE MEASURE: Patients' urban-rural residence at first admissions. MAIN OUTCOME MEASURES: Absolute and relative inequality indexes of the following quality indicators after discharge from the first admission: all-cause psychiatric readmission at 2 and 4 years, dropout of psychiatric outpatient service at 30 days, and emergency department (ED) treat-and-release encounter at 30 days. RESULTS: Between 1998 and 2007, the 4-year readmission rate decreased from 65% to 58%, the 30-day dropout rate decreased from 18% to 15%, and the 30-day ED encounter rate increased from 8% to 10%. Risk of readmission has significantly decreased in rural and urban patients, but at a slower speed for the rural patients (p=0.026). The adjusted HR of readmission in rural versus urban patients has increased from 1.00 (95% CI 0.96 to 1.04) in 1998-2000 to 1.08 (95% CI 1.03 to 1.12) in 2005-2007, indicating a mild widening of the urban-rural gap. Urban-rural differences in 30-day dropout and ED encounter rates have been stationary over time. CONCLUSIONS: The universal health coverage in Taiwan did not narrow urban-rural inequity of psychiatric service utilisation in patients with psychosis. Therefore, other policy interventions on resource allocation, service delivery and quality of care are needed to improve the outcome of rural-dwelling patients with psychosis.

Why do outcomes of CABG care vary between urban and rural areas in Taiwan? A perspective from quality of care.

OBJECTIVE: This study explores the association between coronary artery bypass surgery (CABG) patients' residence and quality of care in terms of 30-day mortality. DESIGN: A retrospective, multilevel study design was conducted using claims data from Taiwan's Universal Health Insurance Scheme. Hospital and surgeon's CABG operation volume, risk-adjusted surgical site infection rate and risk-adjusted 30-day mortality rate in the previous year were adopted as performance indicators, and the level of quality was evaluated via K-means clustering algorithm. Baron and Kenny's procedures for mediation effect were conducted. SETTING: Hospitals in Taiwan. PARTICIPANTS: Patients who underwent CABG surgeries from 1 January 2008 to 30 September 2011 were identified in this study. However, patients who were under the age of 18 years or above the age of 85(n = 164), with missing data for gender (n = 3) or received surgeries from surgeons who never performed any CABG surgeries (n = 27), were excluded. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Thirty-day mortality. RESULTS: There were 9973 CABG surgeries included in this study. Patients who lived in urban areas received better quality of care (28.90 vs. 21.57%) and enjoyed better outcome (4.33 vs. 6.84%). After the procedure of mediation effect testing, the results showed that the relationship between patient residence's urbanization level and 30-day mortality was partially mediated by patterns of quality of care. CONCLUSIONS: The rural-dwelling CABG patients are less likely to approach the better performing healthcare providers, and this tendency indirectly affects their treatment outcomes. Policymakers still need to develop strategies to ensure better equity in access to quality health care.

Long-term effect of fee-for-service-based reimbursement cuts on processes and outcomes of care for stroke: interrupted time-series study from Taiwan.

BACKGROUND: As healthcare spending continues to increase, reimbursement cuts have become 1 type of healthcare reform to contain costs. Little is known about the long-term impact of cuts in reimbursement, especially under a global budget cap with fee-for-service (FFS) reimbursement, on processes and outcomes of care. The FFS-based reimbursement cuts have been implemented since July 2002 in Taiwan. We examined the long-term association of FFS-based reimbursement cuts with trends in processes and outcomes of care for stroke. METHODS AND RESULTS: We analyzed all 411,487 patients with stroke admitted to general acute care hospitals in Taiwan during the period 1997 to 2010 through Taiwan's National Health Insurance Research Database. We used a quasi-experimental design with quarterly measures of healthcare utilization and outcomes and used segmented autoregressive integrated moving average models for the analysis. After accounting for secular trends and other confounders, the implementation of the FFS-based reimbursement cuts was associated with trend changes in computed tomography/magnetic resonance imaging scanning (0.31% per quarter; P=0.013), antiplatelet/anticoagulant use (-0.20% per quarter; P<0.001), statin use (0.18% per quarter; P=0.027), physiotherapy/occupational therapy assessment (0.25% per quarter; P<0.001), and 30-day mortality (0.06% per quarter; P<0.001). CONCLUSIONS: There are improvement trends in processes and outcomes of care over time. However, the reimbursement cuts from the FFS-based global budget cap are associated with trend changes in processes and outcomes of care for stroke. The FFS-based reimbursement cuts may have long-term positive and negative associations with stroke care.

Impact of cuts in reimbursement on outcome of acute myocardial infarction and use of percutaneous coronary intervention: a nationwide population-based study over the period 1997 to 2008.

BACKGROUND: The impact of cuts in reimbursement, such as the Balanced Budget Act in the United States or global budgeting, on the quality of patient care is an important issue in health-care reform. Limited information is available regarding whether reimbursement cuts are associated with processes and outcomes of acute myocardial infarction (AMI) care. OBJECTIVES: We used nationwide longitudinal population-based data to examine how 30-day mortality and percutaneous coronary intervention (PCI) use for AMI patients changed in accordance with the degree of financial strain induced by the implementation of hospital global budgeting since July 2002 in Taiwan. METHODS: We analyzed all 102,520 AMI patients admitted to general acute care hospitals in Taiwan over the period 1997 to 2008 through Taiwan's National Health Insurance Research Database. Multilevel logistic regression analysis was performed after adjustment for patient, physician, and hospital characteristics to test the association of reimbursement cuts with 30-day mortality and PCI use. RESULTS: The mean magnitude of payment reduction on overall hospital revenues was highest (10.02%) during the period 2004 to 2005. Large reimbursement cuts were associated with higher adjusted 30-day mortality. There was no statistically significant correlation between reimbursement cuts and PCI use. CONCLUSIONS: The mortality of AMI patients increases under increased financial strain from cuts in reimbursement. Nevertheless, the use of PCI is not affected throughout the study period. Reductions in the quantity or quality of services with a negative contribution margin or high cost, such as nurse staffing, may explain the association between reimbursement cuts and AMI outcome.

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.