Use of Hospital Referral Regions in Evaluating End-of-Life Care.

Background: Hospital referral regions (HRRs) are often used to characterize inpatient referral patterns, but it is unknown how well these geographic regions are aligned with variation in Medicare-financed hospice care, which is largely provided at home. Objective: Our objective was to characterize the variability in hospice use rates among elderly Medicare decedents by HRR and county. Methods: Using 2014 Master Beneficiary File for decedents 65 and older from North and South Carolina, we applied Bayesian mixed models to quantify variation in hospice use rates explained by HRR fixed effects, county random effects, and residual error among Medicare decedents. Results: We found HRRs and county indicators are significant predictors of hospice use in NC and SC; however, the relative variation within HRRs and associated residual variation is substantial. On average, HRR fixed effects explained more variation in hospice use rates than county indicators with a standard deviation (SD) of 10.0 versus 5.1 percentage points. The SD of the residual error is 5.7 percentage points. On average, variation within HRRs is about half the variation between regions (52%). Conclusions: The magnitude of unexplained residual variation in hospice use for NC and SC suggests that novel, end-of-life-specific service areas should be developed and tested to better capture geographic differences and inform research, health systems, and policy.

Predicting Length of Hospice Stay: An Application of Quantile Regression.

BACKGROUND: Use of the Medicare hospice benefit has been associated with high-quality care at the end of life, and hospice length of use in particular has been used as a proxy for appropriate timing of hospice enrollment. Quantile regression has been underutilized as an alternative tool to model distributional changes in hospice length of use and hospice payments outside of the mean. OBJECTIVE: To test for heterogeneity in the relationship between patient characteristics and hospice outcomes across the distribution of hospice days. SETTING: Medicare Beneficiary Summary File and survey data (2014) for hospice beneficiaries in North and South Carolina with common terminal diagnoses. MEASUREMENTS: Distributional shifts associated with patient characteristics were evaluated at the 25th and 75th percentiles of hospice days and hospice payments using quantile regressions and compared to the mean shift estimated by ordinary least squares (OLS) regression. PRINCIPAL FINDINGS: Significant (p < 0.001) heterogeneity in the marginal effects on hospice days and costs was observed, with patient characteristics associated with generally larger shifts in the 75th percentile than the 25th percentile. Mean effects estimated by OLS regression overestimate the magnitude of the median marginal effects for all patient characteristics except for race. Results for hospice payments in 2014 were similar. CONCLUSIONS: Methodological decisions can have a meaningful impact in the evaluation of factors influencing hospice length of use or cost.

Visual abilities distinguish pitchers from hitters in professional baseball.

This study aimed to evaluate the possibility that differences in sensorimotor abilities exist between hitters and pitchers in a large cohort of baseball players of varying levels of experience. Secondary data analysis was performed on 9 sensorimotor tasks comprising the Nike Sensory Station assessment battery. Bayesian hierarchical regression modelling was applied to test for differences between pitchers and hitters in data from 566 baseball players (112 high school, 85 college, 369 professional) collected at 20 testing centres. Explanatory variables including height, handedness, eye dominance, concussion history, and player position were modelled along with age curves using basis regression splines. Regression analyses revealed better performance for hitters relative to pitchers at the professional level in the visual clarity and depth perception tasks, but these differences did not exist at the high school or college levels. No significant differences were observed in the other 7 measures of sensorimotor capabilities included in the test battery, and no systematic biases were found between the testing centres. These findings, indicating that professional-level hitters have better visual acuity and depth perception than professional-level pitchers, affirm the notion that highly experienced athletes have differing perceptual skills. Findings are discussed in relation to deliberate practice theory.