Cost, utilization, and policy of provision of assistive technology devices to veterans poststroke by Medicare and VA.

BACKGROUND: The increase in provision of assistive technology devices (ATDs) has spurred controversy over Medicare policy aimed at reducing cost-policy that forces social isolation and conflicts with legislation, facilitating participation for individuals with disabilities. In contrast, Department of Veterans Affairs (VA) policy does not limit provision of AT to "in home" use only but rather, states "all enrolled and some non-enrolled veterans are eligible for all needed prosthetics." OBJECTIVES: Examine ATD provision policy by comparing 2 systems, Medicare and VA. Empirically analyze differences in ATDs provided, cost, and duplication in provision. RESEARCH DESIGN: Retrospective study of VA databases, including VA Medicare data. SUBJECTS: A population based study of 12,0461 veterans post-stroke. MEASURES: Frequency of provision of ATDs by Health Care Common Procedural Code, purchase price, and capped rental payments. RESULTS: Of the poststroke veteran cohort, 39% received no AT, 56% received AT from the VA only, 1% received AT from Medicare only, and 3% received AT from both the VA and Medicare. Most ATDs were for activities of daily living, followed by walkers/canes/crutches. In specific ATD comparisons, VA costs were substantially lower than Medicare for purchased items and slightly lower than Medicare for capped rental payments. CONCLUSION: VA provides a broader variety of ATDs at a lesser cost than Medicare. Analyses of policy differences between VA and Medicare suggest VA policy is driven by veteran need whereas Medicare policy is driven at least in part, by containing costs that have skyrocketed as a result of fraudulent claims.

Demographic and clinical variation in Veterans Health Administration provision of assistive technology devices to veterans poststroke.

OBJECTIVES: To examine variation in provision of assistive technology (AT) devices and the extent to which such variation may be explained by patient characteristics or Veterans Health Administration (VHA) administrative region. DESIGN: Retrospective population-based study. SETTING: VHA. PARTICIPANTS: Veterans poststroke in fiscal years 2001 and 2002 (N=12,046). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Provision of 8 categories of AT devices. RESULTS: There was considerable regional variation in provision of AT. For example, differences across administrative regions in the VHA ranged from 5.1 to 28.1 standard manual wheelchairs per 100 veterans poststroke. Using logistic regression, with only demographic variables as predictors of standard manual wheelchair provision, the c statistic was .62, and the pseudo R(2) was 2.5%. Adding disease severity increased the c statistic to .67 and the pseudo R(2) to 6.2%, and adding Veteran Integrated Network System further increased the c statistic to .72 and pseudo R(2) to 9.8%. CONCLUSIONS: Our research showed significant variation in the provision of AT devices to veterans poststroke, and it showed that patient characteristics accounted for only 6.2% of the variation. VHA administrative region and disability severity accounted for equivalent amounts of the variation. Our findings suggest the need for improvements in the process for providing AT and/or provider education concerning device provision.

Factors influencing decisions to admit patients to veterans affairs specialized rehabilitation units after lower-extremity amputation.

UNLABELLED: Bates BE, Kwong PL, Kurichi JE, Bidelspach DE, Reker DM, Maislin G, Xie D, Stineman M. Factors influencing decisions to admit patients to Veterans Affairs specialized rehabilitation units after lower-extremity amputation. OBJECTIVE: To understand patient- and facility-level characteristics that influence decisions to admit veterans to a specialized rehabilitation unit (SRU) after a lower-extremity amputation. DESIGN: Database study. SETTING: All Veterans Affairs Medical Centers (VAMCs). PARTICIPANTS: Veterans with lower-extremity amputation discharged from VAMCs between October 1, 2002, and September 30, 2004. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Admission to an SRU. RESULTS: There were a total of 2922 veterans with lower-extremity amputations; 616 patients were admitted to an SRU, whereas 2306 received consultative rehabilitation services only. Patients admitted to an SRU waited longer to have their first rehabilitation assessment after surgery and had middle-range physical and cognitive disabilities. Patients who received consultative rehabilitation services only tended to have greater illness burden. They were more likely to have previous amputation complication, paralysis, or renal failure and either very severe or minimal physical and cognitive disabilities. CONCLUSIONS: The selection of veterans with new lower-extremity amputations for admission to an SRU appears clinically reasonable and based on the likelihood of successful outcomes.

The effectiveness of inpatient rehabilitation in the acute postoperative phase of care after transtibial or transfemoral amputation: study of an integrated health care delivery system.

OBJECTIVE: To compare outcomes between lower-extremity amputees who receive and do not receive acute postoperative inpatient rehabilitation within a large integrated health care delivery system. DESIGN: An observational study using multivariable propensity score risk adjustment to reduce treatment selection bias. SETTING: Data compiled from 9 administrative databases from Veterans Affairs Medical Centers. PARTICIPANTS: A national cohort of veterans (N=2673) who underwent transtibial or transfemoral amputation between October 1, 2002, and September 30, 2004. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: One-year cumulative survival, home discharge from the hospital, and prosthetic limb procurement within the first postoperative year. RESULTS: After reducing selection bias, patients who received acute postoperative inpatient rehabilitation compared to those with no evidence of inpatient rehabilitation had an increased likelihood of 1-year survival (odds ratio [OR]=1.51; 95% confidence interval [CI], 1.26-1.80) and home discharge (OR=2.58; 95% CI, 2.17-3.06). Prosthetic limb procurement did not differ significantly between groups. CONCLUSIONS: The receipt of rehabilitation in the acute postoperative inpatient period was associated with a greater likelihood of 1-year survival and home discharge from the hospital. Results support early postoperative inpatient rehabilitation following amputation.

Multiple system utilization and mortality for veterans with stroke.

BACKGROUND AND PURPOSE: Many Veteran Health Administration (VHA) enrollees receive health services outside the VHA system. However, limited information is available about poststroke utilization and mortality by veterans who used multiple sources of health care. This study assessed the likelihood of 12-month poststroke rehospitalization and mortality of veterans who used VHA only versus those who used multiple sources of care. METHODS: Our retrospective observational study examined veterans living in Florida and diagnosed with acute stroke. We categorized users into 4 groups: VHA-only, VHA-Medicare, VHA-Medicaid, and VHA-Medicare-Medicaid based on their use of each health care program. Logistic regression models were fitted for 12-month poststroke general rehospitalization, recurrent stroke readmission, and mortality, adjusting for sociodemographic and clinical factors. RESULTS: The sample consisted of 29% VHA-only users, 61% VHA-Medicare users, 3% VHA-Medicaid users, and 7% VHA-Medicare-Medicaid triple users. Compared with the VHA-only users, multiple system users were significantly more likely to be rehospitalized for any cause and for recurrent stroke 12-months postindex. Mortality outcomes depended on when the outcome was measured; at the index admission date, we found no significant difference in mortality across the user groups; at the index discharge date, the VHA-only users was less likely to die within the first 12 months than the users of the 2 dual groups (VHA-Medicare and VHA-Medicaid). CONCLUSIONS: Multiple health care source use was common among VHA enrollees with acute stroke in Florida. Multiple system users were more likely to be rehospitalized and the mortality outcomes were dependent on when the outcome was measured.

Clinical factors associated with prescription of a prosthetic limb in elderly veterans.

OBJECTIVES: To determine how advanced age influences prosthetic prescription. DESIGN: Retrospective cohort analysis with theory-driven logistic regression models. A Post Amputation Quality-of-Life (PAQ) framework of outcomes was proposed and empirically tested. SETTING: Veterans Affairs Medical Centers. PARTICIPANTS: Two thousand three hundred seventy-five veterans with lower extremity amputations discharged between October 1, 2002, and September 30, 2003. MEASUREMENTS: Prosthetic prescription within 1 year of amputation. RESULTS: Patients younger than 76 were 4.5 times as likely to receive a prescription compared to those aged 86 and older (odds ratio=4.51, 95% confidence interval=1.36-14.99) after controlling for sex, marital status, living circumstance before hospitalization, anatomical level, etiologies, comorbidities, medical acuity, and initial functional status. Patients admitted from extended care and patients with peripheral vascular disease, systemic sepsis, renal failure, congestive heart failure, psychoses, metastatic cancer, paralysis, or other neurological disorders were less likely to receive a prescription, as were patients who underwent procedures for acute central nervous system disorders, severe renal disease, or serious nutritional compromise. Veterans evaluated initially as more cognitively and physically able had higher likelihood of prosthetic prescription, and those with transtibial amputations had higher likelihood of prosthetic prescription than those with transfemoral amputations. CONCLUSION: Amputees aged 75 and older are less likely to receive a prosthetic limb prescription than younger individuals, even after controlling for comorbidities and functional status. Findings support the PAQ framework, in which contexts, etiologies, anatomic level, comorbidities, medical acuity, and initial function are determinants of outcome. Medical and functional conditions that adversely affect level of energy, ability to move independently, or ability to exercise judgment reduce the likelihood of prosthetic prescription.

Characteristics of community nursing homes serving per diem veterans, 1999 to 2002.

This study compared the characteristics of community nursing homes where veterans received their care with those of facilities that did not treat veterans from 1999 to 2002 using the Centers for Medicare and Medicaid Services (CMS) Online Survey Certification and Reporting system data merged with the CMS Minimum Data Set. A structure, process, and outcome model was used to examine whether the presence of per diem veterans had any impact on multidimensional quality measures. Facilities with any veterans were less likely to meet recommended nurse staffing standards; more likely to have patients with tube feeding, new catheterizations, and mobility restraints; and more likely to have actual harm citations and new pressure sores, plus quality-of-care, quality-of-life, and total deficiencies, than facilities without veterans. The implications of this study are that the U.S. Department of Veterans Affairs may need to examine its contracting policies with community facilities to understand both quality and selection effects that may be occurring.

Assessing and using comorbidity measures in elderly veterans with lower extremity amputations.

BACKGROUND: Understanding comorbidity prevalence and the effects of comorbidities in older veterans with lower extremity amputations may aid in assessing patient outcomes, resource use, and facility-level quality of care. OBJECTIVES: To determine the degree to which adding outpatient to inpatient administrative data sources yields higher comorbidity prevalence estimates and improved explanatory power of models predicting 1-year mortality and to compare the Charlson/Deyo and Elixhauser comorbidity measures. METHODS: A retrospective cohort study applying frequencies, cross-tabulations, and logistic regression models was conducted, including data from 2,375 veterans with lower extremity amputations. Comorbidity prevalence according to the Charlson/Deyo and Elixhauser measures, 1-year mortality rates, and standardized mortality ratios (SMRs) were analyzed. RESULTS: Comorbidity prevalence estimates increased sharply for both the Charlson/Deyo and Elixhauser measures with the addition of data from multiple settings. The Elixhauser compared to the Charlson/Deyo generally yielded higher estimates but did not improve explanatory power for mortality. Modeling expected versus actual deaths produced varying SMRs across geographic regions but was not dependent on which measure or data sources were used. CONCLUSIONS: Merging outpatient with inpatient data may reduce the under coding of comorbidities but does not enhance mortality prediction. Compared to the Charlson/Deyo, the Elixhauser has a more complete coding scheme for comorbid conditions, such as diabetes mellitus and peripheral vascular disease, important to addressing lower extremity amputation etiology.

Therapeutic exercise and depressive symptoms after stroke.

OBJECTIVES: To examine the effect of exercise on depressive symptoms and the effect of baseline depressive symptoms on the benefits from exercise in stroke survivors who have completed acute rehabilitation. DESIGN: Planned secondary analysis of the data from a 9-month randomized, controlled trial. SETTING: Participant homes. PARTICIPANTS: One hundred stroke survivors who had completed acute rehabilitation. INTERVENTION: A progressive, structured, 3-month physical exercise program. MEASUREMENTS: Demographics, stroke characteristics, impairments, functional limitations, the Geriatric Depression Scale, the Stroke Impact Scale, and the Medical Outcomes Study 36-Item Short Form. RESULTS: Baseline rates of depressive symptoms and other stroke sequelae were similar between the two arms. Ninety-three participants were assessed immediately after the intervention (3 months after enrollment), and 80 were assessed 9 months after enrollment. Six (14%) of the exercise group and 16 (35.6%) of the usual-care group had depressive symptoms at 3 months (P = .03). At 9 months, three (7.5%) of the exercisers had significant depressive symptoms compared with 10 (25%) who received usual care (P = .07). Participants with and without baseline depressive symptoms had equivalent treatment-related gains in impairments and functional limitations, but only participants with depressive symptoms had improved quality of life. CONCLUSION: Exercise may help reduce poststroke depressive symptoms. Depressive symptoms do not limit gains in physical function due to exercise. Exercise may contribute to improved quality of life in those with poststroke depressive symptoms.

Daily functioning and quality of life in a randomized controlled trial of therapeutic exercise for subacute stroke survivors.

BACKGROUND AND PURPOSE: The ability of therapeutic exercise after stroke to improve daily functioning and quality of life (QOL) remains controversial. We examined treatment effects on these outcomes in a randomized controlled trial (RCT) of exercise in subacute stroke survivors. METHODS: This is a secondary analysis of a single-blind RCT of a 12-week program versus usual care. Baseline, post-treatment and 6-month post-treatment daily functioning and QOL were assessed by Barthel index, Functional Independence Measure, instrumental activities of daily living, Medical Outcomes Study short-form 36-item questionnaire (SF-36), and Stroke Impact Scale (SIS). RESULTS: Of 100 randomized subjects, 93 completed the postintervention assessment, (mean age 70; 54% male; 81% white; mean Orpington Prognostic Score 3.4), and 80 had 6-month post-treatment assessment. Immediately after intervention, the intervention group improved more than usual care in SF-36 social function (14.0 points; P=0.0051) and in SIS (strength [9.2 points; P=0.0003], emotion [5.6 points; P=0.0240], social participation [6.6 points; P=0.0488], and physical function [5.0 points; P=0.0145]). Treatment was marginally more effective on Barthel score (3.3 points; P=0.0510), SF-36 (physical function [6.8 points; P=0.0586], physical role function [14.4 points; P=0.0708]), and SIS upper extremity function (7.2 points; P=0.0790). Effects were diluted 6 months after treatment ended. CONCLUSIONS: This rehabilitation exercise program led to more rapid improvement in aspects of physical, social, and role function than usual care in persons with subacute stroke. Adherence interventions to promote continued exercise after treatment might be needed to continue benefit.

Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care: executive summary.

BACKGROUND: A panel of experts developed stroke rehabilitation guidelines for the Veterans Health Administration and Department of Defense Medical Systems. METHODS: Starting from previously established guidelines, the panel evaluated published literature through 2002, using criteria developed by the US Preventive Services Task Force. Recommendations were based on evidence from randomized clinical trials, uncontrolled studies, or consensus expert opinion if definitive data were lacking. RESULTS: Recommendations with Level I evidence include the delivery of poststroke care in a multidisciplinary rehabilitation setting or stroke unit, early patient assessment via the NIH Stroke Scale, early initiation of rehabilitation therapies, swallow screening testing for dysphagia, an active secondary stroke prevention program, and proactive prevention of venous thrombi. Standardized assessment tools should be used to develop a comprehensive treatment plan appropriate to each patient's deficits and needs. Medical therapy for depression or emotional lability is strongly recommended. A speech and language pathologist should evaluate communication and related cognitive disorders and provide treatment when indicated. The patient, caregiver, and family are essential members of the rehabilitation team and should be involved in all phases of the rehabilitation process. These recommendations are available in their entirety at http://stroke.ahajournals.org/cgi/content/full/36/9/e100. Evidence tables for each of the recommendations are also in the full document. CONCLUSIONS: These recommendations should be equally applicable to stroke patients receiving rehabilitation in all medical system settings and are not based on clinical problems or resources unique to the Federal Medical System.

Development of an integrated stroke outcomes database within Veterans Health Administration.

A fundamental goal of the Rehabilitation Outcomes Research Center of Excellence is to improve care and outcomes for veterans with rehabilitation needs. To achieve this goal, the Center's primary objective is increasing research capacity. The Integrated Stroke Outcomes Database is a collection of Veterans Health Administration (VHA) clinical and administrative data containing patient information on a cohort of stroke patients found in the Functional Status Outcomes Database (FSOD), National Patient Care Database (NPCD), and other VHA sources. Clinical and administrative data were abstracted from several VHA data sources and linked to form an integrated outcomes database. A primary cohort of stroke patients treated during fiscal year (FY) 2001 was identified from the FSOD. Matching data from the NPCD, Decision Support System, Health Economics Resource Center, and the National Veterans Survey were obtained, merged, and reported in brief. This integrated database structure will provide valuable support to enhance the VHA capacity to perform stroke rehabilitation research.

Evaluation of proxy responses to the Stroke Impact Scale.

BACKGROUND AND PURPOSE: The purposes of this study were to compare proxy-patient responses on each domain of the Stroke Impact Scale (SIS) and the SIS-16, estimate the bias, and evaluate the validity of proxy scores. METHODS: Two hundred eighty-seven patient and proxy pairs from the Kansas City Stroke Registry participated in the study. All patients were assessed in their home or nursing facility between 90 and 120 days after stroke with the use of the modified Rankin Scale Motricity Index (strength), Barthel Index (activities of daily living), Lawton assessment (instrumental activities of daily living), Folstein Mini-Mental State Examination (cognition), and the SIS. Eligible proxies were individuals who were aged > or =18 years, had known the patient for at least 1 year, and saw the patient at least once each week. All proxy interviews were conducted within 7 days of (before or after) the patient's interview. RESULTS: Three hundred seventy-seven patients from the Kansas City Stroke Registry were eligible for the study. Seventy-seven patients or proxies refused participation. Thirteen patients of the consenting patient-proxy pairs were too aphasic or cognitively impaired to complete the interviews and were dropped from the study. Proxies scored patients as more severely affected than patients scored themselves on the SIS-16 and in 7 of 8 domains of the full SIS (5 were statistically significant at alpha=0.05). The proxy bias toward overrating the severity of the patient's condition tended to increase as the severity of the stroke increased. However, the magnitude of the biases between patient and proxy means, as measured by effect size, was small (range, -0.1 to 0.4). The strength of the agreement, as measured by intraclass correlation coefficients, between proxy and patient ranged from 0.50 to 0.83. Agreement was best for the observable physical domains. Both patient and proxy scores in all domains were significantly different across Rankin categories. Concurrent validity for both patient and proxy correlations with the Folstein Mini-Mental State Examination, Barthel Index, Lawton instrumental activities of daily living, and Motricity Index was good to excellent (range, 0.37 to 0.78). CONCLUSIONS: Proxies provide valid information for assessment of stroke outcomes. There are significant differences between patient and proxy reporting on SIS domains and the SIS-16. However, the observed biases are small and not clinically meaningful.

Randomized clinical trial of therapeutic exercise in subacute stroke.

BACKGROUND AND PURPOSE: Rehabilitation care after stroke is highly variable and increasingly shorter in duration. The effect of therapeutic exercise on impairments and functional limitations after stroke is not clear. The objective of this study was to determine whether a structured, progressive, physiologically based exercise program for subacute stroke produces gains greater than those attributable to spontaneous recovery and usual care. METHODS: This randomized, controlled, single-blind clinical trial was conducted in a metropolitan area and 17 participating healthcare institutions. We included persons with stroke who were living in the community. One hundred patients (mean age, 70 years; mean Orpington score, 3.4) consented and were randomized from a screened sample of 582. Ninety-two subjects completed the trial. Intervention was a structured, progressive, physiologically based, therapist-supervised, in-home program of thirty-six 90-minute sessions over 12 weeks targeting flexibility, strength, balance, endurance, and upper-extremity function. Main outcome measures were postintervention strength (ankle and knee isometric peak torque, grip strength), upper- and lower-extremity motor control (Fugl Meyer), balance (Berg and functional reach), endurance (peak aerobic capacity and exercise duration), upper-extremity function (Wolf Motor Function Test), and mobility (timed 10-m walk and 6-minute walk distance). RESULTS: In the intention-to-treat multivariate analysis of variance testing the overall effect, the intervention produced greater gains than usual care (Wilk's lambda=0.64, P=0.0056). Both intervention and usual care groups improved in strength, balance, upper- and lower-extremity motor control, upper-extremity function, and gait velocity. Gains for the intervention group exceeded those in the usual care group in balance, endurance, peak aerobic capacity, and mobility. Upper-extremity gains exceeded those in the usual care group only in patients with higher baseline function. CONCLUSIONS: This structured, progressive program of therapeutic exercise in persons who had completed acute rehabilitation services produced gains in endurance, balance, and mobility beyond those attributable to spontaneous recovery and usual care.

Adherence to postacute rehabilitation guidelines is associated with functional recovery in stroke.

BACKGROUND AND PURPOSE: The purpose of this study was to determine if compliance with poststroke rehabilitation guidelines was associated with better functional outcomes. METHODS: An inception cohort of 288 stroke patients in 11 Department of Veteran Affairs Medical Centers hospitalized between January 1998 and March 1999 were followed prospectively for 6 months. Data were abstracted from medical records and telephone interviews. The primary study outcome was the Functional Independence Motor Score (FIM). Secondary outcomes included Instrumental Activities of Daily Living (IADL), SF-36 physical functioning, and the Stroke Impact Scale (SIS). Acute and postacute rehabilitation guideline compliance scores (range 0 to 100) were derived from an algorithm. All outcomes were adjusted for case-mix. RESULTS: Average compliance scores in acute and postacute care settings were 68.2% (SD 14) and 69.5% (SD 14.4), respectively. After case-mix adjustment, level of compliance with postacute rehabilitation guidelines was significantly associated with FIM motor, IADL, and the SIS physical domain scores. SF-36 physical function was not associated with guideline compliance. Level of compliance with rehabilitation guidelines in acute settings was unrelated to any of the outcome measures. CONCLUSION: Greater levels of adherence to postacute stroke rehabilitation guidelines were associated with improved patient outcomes. Compliance with guidelines may be viewed as a quality-of-care indicator with which to evaluate new organizational and funding changes involving postacute stroke rehabilitation.

Cost differences in VHA acute and subacute rehabilitation units: implications for VHA resource planning.

Within the Veterans Health Administration (VHA), the top tier of postacute rehabilitation care is provided in acute rehabilitation bedservice units (ARBUs). The next level of care is provided in subacute rehabilitation bedservice units (SRBUs). We fitted reduced-form and structural models to explain VHA cost differences between ARBUs and SRBUs across time and for the individual cost components. We included sociodemographic variables, time since stroke onset, care facility, and the Functional Independence Measure at admission as explanatory variables. The multivariable results indicate that total index stay costs are lower in ARBUs by almost $6,000 (or approximately 25%) compared with SRBUs. Moreover, the lower costs observed in ARBUs in this study combined with the higher rates of guideline compliance and improved outcomes in ARBUs found in previous work suggest that stroke rehabilitation in an ARBU may be more cost-effective than stroke rehabilitation in an SRBU.

Survival analysis in amputees based on physical independence grade achievement.

BACKGROUND: Survival implications of achieving different grades of physical independence after lower extremity amputation are unknown. OBJECTIVES: To identify thresholds of physical independence achievement associated with improved 6-month survival and to identify and compare other risk factors after removing the influence of the grade achieved. DESIGN: Data were combined from 8 administrative databases. Grade was measured on the basis of 13 individual self-care and mobility activities measured at inpatient rehabilitation discharge. SETTING: Ninety-nine US Department of Veterans Affairs Medical Centers. PATIENTS: Retrospective longitudinal cohort study of 2616 veterans who underwent lower extremity amputation and subsequent inpatient rehabilitation between October 1, 2002, and September 30, 2004. MAIN OUTCOME MEASURE: Cumulative 6-month survival after rehabilitation discharge. RESULTS: The 6-month survival rate (95% confidence interval [CI]) for those at grade 1 (total assistance) was 73.5% (70.5%-76.2%). The achievement of grade 2 (maximal assistance) led to the largest incremental improvement in prognosis with survival increasing to 91.1% (95% CI, 85.6%-94.5%). In amputees who remained at grade 1, the 30-day hazards ratio for survival compared with grade 6 (independent) was 43.9 (95% CI, 10.8-278.2), sharply decreasing with time. Whereas metastatic cancer and hemodialysis remained significantly associated with reduced survival (both P < or = .001), anatomical amputation level was not significant when rehabilitation discharge grade and other diagnostic conditions were considered. CONCLUSIONS: Even a small improvement to grade 2 in the most severely impaired amputees resulted in better 6-month survival. Health care systems must plan appropriate interdisciplinary treatment strategies for both medical and functional issues after amputation.

Factors associated with VHA costs of care for first 12 months after first stroke.

We examined the use patterns and costs of care for a validated stroke cohort (n = 172) from 13 Department of Veterans Affairs (VA) medical centers 1 year poststroke. Decision Support System (DSS) cost and use data (inpatient and outpatient) are profiled. We provide preliminary information about the costs associated with inpatient and outpatient care and explore the relationship between the cost of stroke care, location of service (inpatient and outpatient), and patient functional outcomes. Data on both clinical and sociodemographic characteristics were abstracted from the medical record and merged with VA DSS cost data from each patient's first year poststroke. Descriptive statistics assessed patterns in treatment costs. We found that DSS costs varied as expected across key indicators, including function, health status, discharge location, and the number of comorbidities. These findings provide broad support for the use of DSS cost data in studies of VA stroke care.