Hospice Capacity to Provide General Inpatient Care: Emergency Department Utilization and Live Discharge Among Cancer Patients.

General inpatient (GIP) hospice care is used only minimally for hospice patients, and more than a quarter of Medicare hospice facilities do not provide GIP care. To determine the impact of hospices' capacity to provide on emergency department use during hospice enrollment and live discharge from hospice, we used Surveillance, Epidemiology, and End Results-Medicare linked data and CMS Provider of Services data from 2007 to 2013 from ten states and two metropolitan regions. Grouping hospices into three GIP care provision categories: 1) no-GIP; 2) GIP-contract; and 3) GIP-IHF where hospices directly provide GIP care in their own inpatient hospice facility (IHF), we built a multilevel logistic model that accounted for unobserved hospice characteristics. Nearly 9% of the study sample received GIP care, of which 82% received such care in the last week of discharge. GIP-IHF hospices had lower live discharge rates than no-GIP hospices (AOR: .61; 95% CI: .47-.79; P < .001) and GIP-contract hospices (AOR: .84; 95% CI: .70-1.00; P < .05). Similarly, GIP-contract hospices were also associated with a decreased risk of live discharge, compared to no-GIP hospices (AOR: .76; CI: .62-.92; P < .05). There was no difference in emergency department use between no-GIP hospices and hospices with such capacity. Our results suggest that hospices capable of providing GIP care have lower live discharge rates than their counterparts. However, the fact that GIP care tends to be provided too close to death limits its effectiveness in preventing avoidable emergency department use.

Development of a Spanish-Language Hospice Video.

The nation faces a persistent issue of delayed access to hospice care. Even though hospice enrollment is considered to be one of the most difficult medical decisions, physician clinics and hospitals lack tools for helping patients/families faced with making decisions about enrollment. Health-care literature lacks discussion of development of decision-making aids in the context of hospice decisions for minority ethnic groups, even though those groups have decisional needs that may differ from those of non-Hispanic whites. To fill the gap, we developed a video of a Latino hospice patient with footages showing how the patient was being taken care of by her family with support from a hospice disciplinary team. A primary objective of this article is to describe how focus groups, existing decision aids, and individual interviews were used to develop and improve a Spanish-language hospice educational video targeting Latino subgroups with linguistic, cultural, and educational barriers. These steps may provide guidelines for developing and revising health-related videos targeting other minority ethnic groups.

Hospice agencies' hospital contract status and differing levels of hospice care.

In response to a 2011 finding that approximately 27% of Medicare-certified hospices do not provide a single day of general inpatient care (GIP), the authors explored the extent to which hospices have contracts with hospitals for GIP. Using the 2007 National Home and Hospice Care Survey, we estimated that 1119 (32%) agencies had no contract with any hospitals in 2007 and half of those with no contract did not have a contract with a skilled nursing facility (SNF) either. As a result, these hospices were unable to provide GIP referrals for those in need of inpatient care for acute pain and symptom management. More importantly, not having a contract with a hospital was just one of the factors influencing GIP provision. In the multivariate logistic model, after controlling for contract status with a hospital and other hospice characteristics, agencies in the second quartile of hospice patient census (12-29 vs 73 or more, adjusted odds ratio = 14.10; 95% confidence interval 4.26-46.62) were independently related to providing only routine home care. These hospices are more likely to rely solely on scatter beds for GIP provision. Given that a significant portion of hospices do not have a contract with a hospital, policy makers need to understand barriers to contracts with a hospital/SNF for GIP and consider a hospice's contract status as one of the standards for hospice certification. In addition, further research is necessary to understand why hospices that do have a contract with a hospital do not make GIP referral.

Assessment of levels of hospice care coverage offered to commercial managed care plan members in California: implications for the California Health Insurance Exchange.

The implementation of the Affordable Care Act that provides for the expansion of affordable insurance to uninsured individuals and small businesses, coupled with the provision of mandated hospice coverage, is expected to increase the enrollment of the terminally ill younger population in hospice care. We surveyed health insurance companies that offer managed care plans in the 2014 California health insurance exchange and large hospice agencies that provided hospice care to privately insured patients in 2011. Compared with Medicare and Medicaid hospice benefits, hospice benefits for privately insured patients, particularly those enrolled in managed care plans, varied widely. Mandating hospice care alone may not be sufficient to ensure that individuals enrolled in different managed care plans receive the same level of coverage.

Characteristics of hospice patients utilizing hospice inpatient/residential facilities.

Given the increasing popularity of a hospice inpatient/residential facility (HIRF) among hospice patients and their family members, examining who uses HIRFs has been of increasing importance. Using the 2007 National Home and Hospice Care Survey (NHHCS), we found that about 14% of the hospice patients received care in an HIRF in 2007. Characteristics of patients associated with HIRF use largely match the industry norm for a general inpatient level of care and include having no caregiver or having an incapable caregiver; having imminent death; and being directly admitted to a hospice after discharge from a hospital. Given a recent stricter enforcement of reimbursement rules, however, we call for close monitoring of any change in the number of HIRF beds--particularly in rural and low-income urban areas.

Determinants of primary care physicians' referral pattern: a structural equation model approach.

This study examines patient referrals by primary care physicians (PCP) with nurse practitioners and physician assistants (NP-PA) in their medical practices as compared to practices without them. The study uses data from the Robert Wood Johnson Foundation community tracking study (CTS) Physician Survey, Round I (1996-97) and II (1998-99). Structural equations with binary dependent variables were used to examine the links among managed care, the use of NP-PA, the complexity of patient's conditions, and the number of referrals. PCP's with NP-PA were found to have a greater likelihood of treating patients with complex conditions instead of referring them to specialists. Managed care related variables (i.e., large group practice/HMO, the percentage of patients for whom PCPs acted as gatekeepers, and the percentage of managed care revenue from capitated/prepaid contracts) affected PCP' patient referrals, but only through the increased use of NP-PA. PCP's with NP-PA were also found to provide appropriate care to the complex patients. These findings indicate that NP-PA enable PCP to concentrate on patients with more complex conditions thus reducing the number of referrals. In addition, NP-PA is found to affect the gatekeeper role of PCPs.

Does caregiver knowledge matter for hospice enrollment and beyond? Pilot study of minority hospice patients.

We examined the level of hospice knowledge of caregivers of minority elderly hospice patients and determined how it influences the hospice enrollment decision and the decision on the use of hospice services after enrollment. Based on qualitative analysis of medical records and interviews with caregivers of minority elderly hospice patients who received personal care from paid caregivers (eg, other than family caregivers), we found that hospice knowledge increased access to hospice among minority patients who otherwise would not opt for hospice or enroll too late for comprehensive hospice care services. Furthermore, the highest level of knowledge-acquired through caregivers' health care occupations-appears to influence hospice care after hospice enrollment. Caregivers with that level of knowledge made requests for changes in site of care and/or additional services that may enhance the quality of hospice care that their loved ones receive.

Ethnic variation in timing of hospice referral: does having no informal caregiver matter?

BACKGROUND: The length of hospice stay, as an indicator of timing of hospice referral, is an important outcome to examine in end-of-life care because it is relevant to the quality and cost efficiency of end-of-life care that patients receive. Although the majority receives nonmedical care from informal caregivers, many elderly hospice users rely on paid caregivers or staff of residential facilities. OBJECTIVE: This study examined whether availability of informal primary caregiver interact with ethnicity to affect length of hospice stay. DESIGN: A retrospective cross-sectional study. SETTING/SUBJECTS: Data on 3024 hospice patients aged 65 and older discharged between 1997 and 2000 was extracted from the National Center for Health Statistics' National Home and Hospice Care Survey (NHHCS). MEASUREMENTS: Length of hospice stay prior to death or discharge. RESULTS: Survival analysis revealed that among patients with formal caregivers, minority patients were likely to have significantly shorter hospice stays than non-Hispanic whites. There were no significant ethnic differences in length of stay among patients with informal caregivers. CONCLUSIONS: Our findings suggest that ethnic differences in length of stay should be discussed in terms of type of caregiver, not just type of setting, since patients in residential facilities can have informal primary caregivers who are vigilant advocates for their dying relatives. We discuss possible reasons for the influence of having formal caregivers on length of stay of minority elders.

Factors underlying racial disparities in hospital care of congestive heart failure.

OBJECTIVE: To examine relationships between race and five aspects of hospital care. METHODS: Cross-sectional data of 373,158 discharges with heart failure in the 1995-1997 National Inpatient Sample were used to measure severity, care-seeking patterns, processes, resource consumption, and outcomes. RESULTS: Compared to White patients, African American and Hispanic patients were more likely to seek care through the emergency department (ED) but less likely to receive clinical procedures or die in the hospital. Interactions of African American race with patient co-morbidity status, admission through the ED, and receipt of intensive services were associated with lower mortality as was interaction between admission to teaching hospitals and Hispanic race. CONCLUSIONS: Lack of access to ambulatory care among minority patients and hospital care via the safety net may contribute to racial discrepancies as a result of healthier patient selection among minority groups.

Current issues in health care informatics.

Health care informatics has emerged as a diverse and important new field of study. The field can be very broadly defined as the science that addresses how best to use information to improve health care. The field includes the four areas of bioinformatics, medical informatics, public health informatics, and consumer health informatics. Health care informatics applications can be used to improve the quality of patient care, to increase productivity, and to provide access to knowledge. After providing an overview of the field, the 10 articles contained in this special issue are briefly discussed. The first six articles address a diverse set of topics such as the use of health care informatics to conduct research, clinical information systems used by the U.S. Air Force, electronic medical records and physician satisfaction in Oman, and a point of care documentation system used by hospice care providers. The last four articles discuss the complex issues raised by the implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

A point of care clinical documentation system for hospice care providers.

This article identifies two areas of hospice care that may benefit the most from a point-of-care (POC) clinical documentation system: documentation for recertification and symptom/pain management. Applications as solutions for the hospice POC clinical documentation system need two documentation support tools: (1) knowledge-based external or internal reference data available to physicians or medical staff right at the bedside and (2) assisting medical staff in filling out electronic forms for clinical measurements by providing real-time prompts, clues, alerts, or other types of feedback, along with the common features such as pre-defined values in specific fields. Our study may encourage more software vendors to include clinical documentation support tools in their solutions.

Overview of administrative simplification provisions of HIPAA.

The administrative simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 are considered to have a considerable impact on the health care industry in the United States of America. The HIPAA-mandated electronic transactions using Electronic Data Interchange (henceforth EDI) methods have brought significant issues on privacy, confidentiality and security for individually identifiable information not to mention technical issues. The purpose of this paper is to facilitate the understanding of those issues surrounding the administrative simplification part of HIPAA. Toward this goal, the paper provides an overview of HIPAA through a systematic approach of understanding its evolution and its requirements.

Health and GIS: toward spatial statistical analyses.

This study examined the extent to which health studies, mostly in public health and epidemiology, used geographical information systems (GIS). We identified a wide range of tools they used-ranging from geocoding through simple buffer/overlay functions to spatial query functions. However, studies tend to rely on tools outside of GIS for spatial statistical analyses. This may reflect a lack of spatial statistical tools that are suitable for health researchers whose data are rather geographically aggregated count data than continuous data. Implementation within GIS of spatial analytical tools suitable for aggregated data over a region will increase the use of GIS beyond simple GIS operations in health studies.

Geographic information systems in public health and medicine.

Geographic information systems (GIS) are increasingly being used in public health and medicine. Advances in computer technology, the encouragement of its use by the federal government, and the wide availability of academic and commercial courses on GIS are responsible for its growth. Some view GIS as only a tool for spatial research and policy analysis, while others believe it is part of a larger emerging new science including geography, cartography, geodesy, and remote sensing. The specific advantages and problems of GIS are discussed. The greatest potential of GIS is its ability to clearly show the results of complex analyses through maps. Problems in using GIS include its costs, the need to adequately train staff, the use of appropriate spatial units, and the risk it poses to violating patient confidentiality. Lastly, the fourteen articles in this special issue devoted to GIS are introduced and briefly discussed.

Toward efficient medication error reduction: error-reducing information management systems.

Hospitals and other health-care providers today are being pressed more than ever to use technologies for reducing medical errors. Particularly, medication errors are likely to increase fast as Americans age. This paper intends to provide a starting point for understanding information technologies and database systems supporting such technologies as Computerized Physician Order Entry (CPOE), Automated Dispensing System (ADS), and Bar Coding System designed to reduce medication errors in hospitals. Although vendors provide the necessary communication software and applications, actions involving governments, technology vendors, pharmaceutical companies, and clinical researchers are needed to put to actual use the applications with a massive potential to significantly reduce medication-related errors.

Access to microdata on the Internet: Web-based analysis and data subset extraction tools.

The Internet is increasingly being recognized as an invaluable component of education. At the college and university level, online databases and statistical tools for Web-based analysis and data subset extraction have become important instructional resources. These Internet resources enable students to formulate specific research hypotheses, identify relevant variables, and analyze large existing databases. This article describes three of these resources: the Federal Electronic Research and Review Extraction Tool (FERRET) of the U.S. Bureau of the Census, the Survey Documentation and Analysis (SDA) unit at the University of California, Berkley, and the Inter-University Consortium for Political and Social Research (ICPSR), which is housed at the University of Michigan.