Robin E. Remsburg

Differences in hospice use between black and white patients during the period 1992 through 2000.

Purpose:We examined differences in hospice use rates among blacks and whites and investigated trends in racial differences in hospice patients during the period 1992 through 2000. We tested differences in length of hospice survival from hospice enrollment to death between black and white patients during this period. Methods:We analyzed data from the 1991–2000 Underlying and Multiple Cause-of-Death Files and the 1992–2000 National Home and Hospice Care Surveys using z tests, &khgr;2 tests, and Cox regression models. Results:Compared with 1992, the hospice use rate doubled for white patients (P < 0.0001) and increased almost 4-fold for black patients (P < 0.0001) in 2000. Hospice use rates among black patients were significantly lower than those among white patients from 1992 to 1994 but not from 1996 to 2000. Black hospice patients discharged throughout the 1990s were more likely to be younger, have Medicaid-only as their payment source, and have HIV/AIDS than their white counterparts. Black hospice patients were more likely to be referred by hospitals than white hospice patients during 1996 to 2000. Throughout the 1990s, length of hospice survival did not significantly differ between black and white hospice patients after adjusting for covariates. Conclusions:Hospice use rates significantly increased for both whites and black patients. Black patients had lower hospice use rates than white patients from 1992 to 1994, but not from 1996 to 2000, which may reflect the diffusion of hospice care to black patients with the rapid growth in hospice programs. Despite differences in patient characteristics, the length of hospice survival was similar among both groups. Future research is needed to assess whether racial disparities exist in quality of hospice care.

Payment source and length of use among home health agency discharges.

Purpose:Our study compared (1) length of use among home health care (HHC) discharges with Medicare, Medicaid, or private health insurance between 1991 and 2000 and (2) factors associated with length of HHC use among discharges with Medicare, Medicaid, or private health insurance. Methods:Data were obtained from the 1992, 1994, 1996, 1998, and 2000 National Home and Hospice Care Surveys (n = 18,416). Logistic regressions and stratified analyses by primary payment source were applied. Results:After adjusting for covariates, Medicare HHC patients were from 0.52 to 0.75 times less likely to be discharged within 30 days in 1991–1996 than in 1997–1998. Medicaid patients were 0.37 times less likely to be discharged within 30 days in 1991–1992 than in 1997–1998. Patients with private insurance were 2.05 times more likely to be discharged within 30 days in 1993–1994 than in 1997–1998. No significant difference in length of use was found at the multivariate level between 1997–1998 and 1999–2000 among HHC patients with Medicare, Medicaid, or private health insurance. Results for being discharged within 60 days were similar to these described above. Conclusions:Our study shows that length of HHC use among Medicare discharges decreased after the implementation of the Medicare interim payment system. We did not find a spillover effect of the Medicare interim payment system on length of HHC use among discharges with Medicaid or private health insurance. Our results can help health professionals and policy makers better understand the dynamic associations between payment systems and length of use of HHC services.

Influenza immunization in nursing homes: Who does not get immunized and whose status is unknown?

OBJECTIVE To identify nursing home resident and facility characteristics associated with patients not receiving influenza immunization and having unknown immunization status. DESIGN Secondary data analysis using multinomial logistic regression of data from the National Nursing Home Survey, a nationally representative establishment-based survey. SETTING A total of 1,423 nursing facilities of all ownerships and certifications systematically sampled with probability proportional to number of beds. PATIENTS A total of 7,350 randomly sampled people aged 65 years or older residing in nursing homes between July and December 1999 (approximately 6 per facility). MAIN OUTCOME MEASURE Immunization status of residents. RESULTS Fifteen percent of residents were not immunized and 19% had unknown immunization status. In multivariate analysis, lack of immunization and unknown immunization status were each separately associated with being newly admitted, with no or unknown pneumococcal immunization, and with facility failures to screen for immunization and to record inoculation in the medical record. High-risk status and staff immunization requirements had no effect. Separate analyses showed that residents with unknown immunization status are statistically significantly different from both those vaccinated and those not vaccinated. CONCLUSION This study indicates that both resident and facility characteristics are associated with failure to be immunized for influenza. Facilities should consider targeting younger, newly admitted, and residential care residents for influenza immunization, since they are more likely to be missed. Further research into the barriers to immunization specific to nursing home resident choice or opportunity may be warranted.

Impact of the Medicare Interim Payment System on Length of Use in Home Care Among Patients with Medicare-Only Payment Source

ABSTRACT Using data from the 1996 and 2000 National Home and Hospice Care Surveys (N = 2455), we examined length of use in home care among patients with Medicare-only payment source before and during the Medicare interim payment system (IPS). Logistic regression analyses revealed that patients were 2.9 times more likely to be discharged within 60 days during IPS than before IPS. The impact of Medicare IPS on length of use in home care among patients with Medicare only was stronger than what the existing literature indicates, which combines Medicare patients with multiple payment sources and patients with Medicare-only together.

Nursing Home Resident and Facility Characteristics Associated with Pneumococcal Vaccination: National Nursing Home Survey, 1995–1999

Objectives: To assess Advisory Committee for Immunization Practices recommendations for the pneumococcal vaccine in nursing home residents using national surveys to examine factors associated with vaccination.

Pneumococcal Vaccination in Nursing Homes: Does Race Make a Difference?

OBJECTIVES Known disparities in pneumococcal vaccination in the community raise the question of whether disparities also exist in the nursing home setting, which is better controlled. This study used nationally representative nursing home data to compare black and white nursing home residents with respect to receiving, not receiving, or having an unknown PPV vaccination status, and to examine the interaction of race with various facility characteristics. DESIGN Multinomial logistic regression was used to analyze a 2-year merged file (1997 and 1999) of the National Nursing Home Survey, a cross-sectional national probability sample of nursing homes and residents. SETTING AND PARTICIPANTS Residents 65 years or older (n = 14,782) residing in nursing homes between July and December of 1997 or 1999. MEASUREMENTS Record-based staff report of whether residents ever had a pneumococcal immunization (yes/no/unknown); race measured as black or white. RESULTS Pneumococcal vaccination rates are lower for black nursing home residents than for white residents, as shown using a merged file of the 1997 and 1999 National Nursing Home Surveys. Participants include 14,303 randomly sampled residents 65 years or older. In this sample, 31% of black residents compared with 24% of white residents 65 years or older had never received pneumococcal vaccination (P < .01). Multivariate logistic regression confirmed that blacks were more likely to be unimmunized than whites (95% CIs), specifically in Medicaid-only facilities and dually certified Medicare and Medicaid facilities. Blacks also had higher odds of unknown vaccination status than whites in Medicaid-only facilities and lower odds of unknown status in government-owned facilities. CONCLUSIONS Results suggest that the racial difference in pneumococcal vaccination exists predominantly in certain facility types. In addition, facility-based interventions such as having an organized PPV immunization program or improving documentation of vaccination status can be effective in increasing vaccination rates for all races.