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Objective: To construct a data tool, the Residential History File (RHF), that summarizes information from Medicare claims and nursing home (NH) Minimum Data Set (MDS) assessments to track people through health care locations, including non-Medicare-paid NH stays.Data Sources: Online Survey of Certification and Reporting (OSCAR) data for 202 free-standing NHs, Medicare Denominator, claims (parts A and B), and MDS assessments for 60,984 people who were present in one of these NHs in 2006.Methods: The algorithm creating the RHF is outlined and the RHF for the study data are used to describe place of death. The identification of residents in NHs is compared with the reports in OSCAR and part B claims.Principal Findings: The RHF correctly identified 84.8 percent of part B claims with place-of-service in NH, and it identified 18.3 less residents on average than reported in the OSCAR on the day of the survey. The RHF indicated that 17.5 percent non-Medicare NH decedents were transferred to the hospital to die versus 45.6 percent skilled nursing facility decedents.Conclusions: The population-based design of the RHF makes it possible to conduct policy-relevant research to examine the variation in the rate and type of health care transitions across the United States. [ABSTRACT FROM AUTHOR]

The unique needs of the terminally ill patient may require more planning and service coordination than those of the nonterminal patient. The hospice interdisciplinary team was a response to these additional needs. This paper examines the pattern of patient care and administrative activities of paid hospice staff by hospice organizational type and demonstration status in the National Hospice Study. Data gathered over a one year period revealed that demonstration hospices, in which all allowable costs were Medicare reimbursed, spent significantly more time in general and patient related administrative activities than non-demonstration hospices, which operated within existing Medicare cost limits. Staff in demonstration home care-based hospices reported significantly longer home visits than staff in non-demonstration hospices. In both groups, home carebased hospice visits were of longer duration than those home visits conducted by staff of hospital-based hospices. [ABSTRACT FROM AUTHOR]

We investigated county-level variation in mRNA COVID-19 vaccine use among Medicare beneficiaries throughout the United States. There was greater use of Pfizer-BioNTech vaccines than Moderna vaccines in urban areas for first and booster doses.

Purpose: The effectiveness of pharmaceutical care planning software for nursing homes and the extent to which the software assisted in the implementation of the Fleetwood Model are described., Methods: During the study, one long-term-care pharmacy identified 13 nursing homes to participate in the intervention group of a study evaluating the effectiveness of the Fleetwood Model. To successfully implement the Fleetwood Model, which demands prospective drug regimen review and collaborative practices between dispensing and consultant pharmacists, a software system that exchanged information between these pharmacists was deemed necessary. Pharmacists' self-reported assessments of the use of the software and the technical difficulties reported with its use were collected. The number of interventions performed by pharmacist type, the proportion of residents receiving interventions by multiple pharmacists, and the extent to which the interventions were prospective and performed before the mandated 30-day review were estimated from data documented in the software. The consistency of software use by the pharmacists was also estimated., Results: Seventy-one percent of dispensing pharmacists and 40% of consultant pharmacists reported using the software most or all of the time. Fourteen percent of dispensing pharmacists and 40% of consultant pharmacists reported technical difficulties with the software. Over half of newly admitted or readmitted residents received a Fleetwood intervention within 3 days of admittance into the nursing home-71.2% occurred in less than 30 days of admission., Conclusion: The use of information technology to increase communication among health care professionals and assist in providing prospective drug regimen review in long-term-care facilities is feasible. Collaboration and extensive field testing with end users, realistic expectations, appropriate training, and technical support are necessary when implementing new technology.

Objectives: The Health Care Financing Administration requires that patients admitted to certified nursing homes be assessed with the Minimum Data Set, a data collection instrument containing more than 300 demographic, diagnostic, clinical, and treatment variables. Long-term care databases potentially may be used to assess the outcomes of specific treatments as well as drug effectiveness. The authors sought to ascertain reliability and validity of diagnostic and drug data in a database obtained by merging the Minimum Data Set with detailed information on drugs consumed by each resident., Methods: A population of 296,379 residents of 1,492 nursing homes in Kansas, Maine, Mississippi, New York, and South Dakota participated in the study between 1992 and 1994. Minimum Data Set clinical diagnoses were contrasted with selected resident characteristics and a variety of symptoms and treatments. Limited to individuals who had been hospitalized in the 6 months preceding the first assessment, Minimum Data Set diagnoses were compared with those on the hospital discharge claims maintained in the Medicare Provider Analysis and Review database. Finally, the probability that the use of selected drugs predicted the correspondent gender-specific, age-specific, or unique labeled indication was estimated., Results: The positive predictive value for Minimum Data Set diagnoses compared with gender or function measures exceeded 0.9, and it was 0.8 for specific symptoms and 0.6 for virtually all other comparisons. The positive predictive value for Minimum Data Set diagnoses compared with those from hospital claims was approximately 0.7 for all chronic medical conditions, except for depression and asthma/chronic obstructive pulmonary disease/emphysema. The positive predictive value for acute/subacute diagnoses (ie, pneumonia, urinary tract infection, anemia) that may resolve during hospital stay was less than 0.5. The positive predictive value for selected drugs, except estrogens, compared with age and gender was close to 1.0 in all cases. When compared to their labeled indication, the positive predictive value was more than 0.6 for all drugs considered, with 0.97, 0.91, and 0.87 for tacrine and Alzheimer's disease, antidiabetics and diabetes mellitus, and L-dopa and Parkinson's disease, respectively., Conclusions: These findings point to the overall validity of the drug and clinical data in this Minimum Data Set-based data set. Additional validation efforts will determine whether this data set can be used for studies of geriatric pharmacoepidemiology and for analyses of the influence of different policies and practices on residents' outcomes.

Objective: To compare the rates of hospitalization among cohorts of nursing home residents assembled before and after the implementation of the federally mandated Resident Assessment Instrument (RAI)., Sample: Subjects were nursing home residents chosen from 268 facilities in major Metropolitan Statistics Areas in 10 states and representing more than 1500 facilities and 60,000 residents. Two resident cohorts (1990 and 1993) were sampled (8 to 16 residents per facility, depending upon facility size) as part of an evaluation of the impact of implementing the RAI., Methods: Research nurses reviewed records, interviewed staff, observed patients, and completed an RAI at baseline and 6 months later. All transitions during this interval (hospital admissions, nursing home transfers, returns home, death, etc.) were tracked. Using polytomous logistic regression, we tested the effect of cohort on the probability of being hospitalized in light of the competing risks of dying or remaining in the home, controlling for demographic and casemix variables, and having a DNR order in the chart., Results: A total of 4196 residents were studied, 2118 in 1990 (age 81.3, female 77.7%, LOS 6+ months 49.8%) and 2078 in 1993 (age 81.7, females 75.5%, LOS 6+ months 50.2%). The unadjusted probability of hospitalization dropped from .205 to .151. Multivariate analyses revealed a significant adjusted odds of hospitalization of .74 (95% CI .60-.91) and no cohort effect on home discharge or death. Among severely cognitively impaired residents, the adjusted odds of hospitalization in 1993 compared with the 1990 cohort was 0.74 (.53-1.03). Finally, among survivors in both cohorts who had a follow-up MDS performed, and whose ADL remained stable, 15.9% were hospitalized in 1990, whereas only 10.9% were hospitalized in 1993. On the other hand, ADL decliners were more likely to have been hospitalized in 1993 than in 1990 (40.6% vs 25.2%)., Conclusions: Although other changes in the industry, clinical practice, and health care policy may have influenced hospitalization of nursing home residents, the substantial reductions observed among the cognitively impaired and those with stable ADL suggest superior and uniform assessment information in the form of the RAI contributed significantly to this decline.

The Medicare Catastrophic Coverage Act (MCCA) of 1988 altered eligibility and coverage for skilled nursing facility (SNF) care and changed Medicaid eligibility rules for nursing-home residents. Detailed data on the residents of a for-profit nursing-home chain and Medicare claims for a 1 percent sample of beneficiaries were used to examine the impact of the MCCA on nursing homes. The case mix of nursing-home admissions was scrutinized, specifically for length of stay, discharge disposition, rate of hospitalization, and changes in payer source. Findings revealed that, although the proportion of Medicare-financed nursing-home care increased, as did the case-mix severity of residents during the MCCA period, there was no corollary reduction in hospital use by nursing-home residents.

Objective: To describe patterns of psychotropic use as well as clinically relevant and concurrent nonpsychotropic use among older residents of board and care facilities in 10 states., Methods: Weighted use rates were based on data from a sample of 2054 residents aged 65 and older from 410 facilities in 10 states, drawn via a complex, multistage sampling design. Data, including drug name, use frequency, and PRN use, were collected on all drugs taken by the resident during a 7-day period. During face-to-face interviews with residents and/or proxies, data were also collected on resident characteristics., Subjects: The majority of subjects were female, white, and widowed. Average age was 82 years. Approximately 25% had a current mental or emotional condition, and 8% had been hospitalized for a psychiatric condition during the year before admission. More than half needed help with at least one activity of daily living. Forty percent had moderate or severe cognitive impairment, and 18% had received mental health care during the previous year., Analyses: Weighted descriptive analyses were performed with Software for Survey Data Analysis (SUDAAN), which accounts for the complex, multistage sampling design., Results: Approximately 35% of the older residents used at least one psychoactive agent, with 30% of psychotropic users receiving two to four different psychotropic medications. Use rates decline with age, for psychotropics overall and for therapeutic classes. Results revealed potentially problematic polypharmacy in relation to drug duplication within therapeutic classes, use of multiple psychotropics across classes, and concurrent nonpsychotropic use., Conclusions: Compared with community-dwelling older adults, this study revealed high psychotropic use rates among older board and care facility residents. Overall, our results suggest that serious consideration be given to the apparent need for systematic drug utilization review, a potentially useful program that is mandated in other settings.

Standard functional assessment instruments often fail to capture subtle impairment in community-dwelling older persons. To create a scale to measure function at the Advanced Activities of Daily Living (AADL) level, we chose three questions to separate a community sample into four levels: frequent vigorous exercisers (8.0%), frequent long walkers (10.8%), frequent short walkers (23.7%), and nonexercisers (57.5%). These levels of exercise formed a hierarchical scale that correlated positively in a graduated manner with progressively advanced social activities of daily living, current health status, and mental health. At 1-year follow-up, 20% of persons declined in exercise level, 63% showed no change in exercise level, and 17% improved their exercise level. Changes in exercise level in both directions were associated with changes in mental health status. The Advanced Activities of Daily Living scale may be a sensitive measure of earlier functional decline, but longer follow-up will be necessary to determine its clinical usefulness.

Little systematic research has been reported on analgesic use in terminal cancer patients. This paper presents data from the National Hospice Study on the use of analgesics by a sample of terminal cancer patients served in home based and hospital based hospice programs as well as conventional oncological settings. Patients in hospital based hospice programs were more likely than other patients to have an analgesic prescription and to have consumed analgesics. Patients in hospice settings were more likely to consume analgesia orally and less likely to have "prn" (as needed) analgesic prescriptions. The amount of analgesic consumption was inversely related to age. The paper discusses the implications of these and other findings for the treatment of pain in terminal cancer patients.

Planning terminal care for patients with malignant neoplasms is difficult, in part, because accurate measures of prognosis have not been defined. Using data from the National Hospice Study, we examined the correlation of 14 easily assessable clinical symptoms with survival in patients with terminal cancer. Performance status was the most important clinical factor in estimating survival time, but five other symptoms had independent predictive value as well (shortness of breath, problems eating or anorexia, trouble swallowing, dry mouth, and weight loss). We generated four parametric accelerated time survival models to estimate survival in patients with combinations of these symptoms and validated the log-normal model on the entire data set. This model was unaffected by patient age, sex, primary tumor type, or site. Our findings illustrate the value of biologically "soft" clinical data in predicting survival in patients with terminal cancer. The prevalence of similar symptoms among patients with cancer of various primary and metastatic sites also supports the concept of a common final clinical pathway in patients with advanced malignant neoplasms.

Debilitating pain is the symptom most often associated with cancer by the general public. The National Hospice Study (NHS) evaluated pain control among terminal cancer patients served in hospital based (HB) and home based (HC) hospices, and in conventional care settings (CC) such as outpatient clinics and oncology units. Pain was reported by the patient when able to respond and by the patients' primary care person (PCP) during repeated interviews until death. Patient and PCP pain reports were correlated at 0.43. PCPs reported that around 16% of patients were pain free in the last weeks of life while 18% were in persistent pain. Statistically adjusting for differences in the CC, HB, and HC samples, HB patients were less likely to report having persistent pain than either CC or HC patients, although there were no differences in the proportion of patients who were pain free. Age was negatively correlated with the level of pain. As expected, brain and bone metastases were related to pain in opposite directions, with more pain among those with bone involvement and less among those with brain involvement. Conclusions about whether HB hospices really are superior at pain control must be made cautiously in view of the relationship between age and pain and the greater age of hospice patients in our study.