Chapter 2. Effectiveness (continued, 3)

National Healthcare Quality Report, 2008


Respiratory Diseases

Importance

Type of statisticNumber
Mortality
Number of deaths due to lung diseases (2004)226,37938
Number of deaths, influenza and pneumonia combined (2005)63,0012
Cause of death rank, influenza and pneumonia combined (2005)8th2
Prevalence
Adults age 18 and over who have asthma (2006)16,057,00039
Children under age 18 who have asthma (2006)6,819,00039
Incidence
Annual number of cases of the common cold (est.)>1 billion40
Annual number of pneumonia cases due to Streptococcus pneumoniae500,00041
New cases of tuberculosis (2007)13,29342
Cost
Total cost of lung diseases (2007 est.)$153.6 billion5
Direct medical costs of lung diseases (2007 est.)$94.8 billion5
Total approximate cost of upper respiratory infections (annual)$40 billion43
Total cost of asthma (2007)$19.7 billion38
Direct medical costs of asthma (2007)$14.7 billion38
Cost-effectiveness of influenza immunization$0-$14,000/QALY6

Note: Statistics may vary from previous years due to revised and updated source statistics or addition of data sources.

Measures

The NHQR tracks several quality measures for prevention and treatment of this broad category of illnesses that includes influenza, pneumonia, asthma, upper respiratory infection, and tuberculosis. The five core report measures highlighted in this section are:

  • Pneumococcal vaccination.
  • Receipt of recommended care for pneumonia.
  • Receipt of antibiotics for the common cold.
  • Completion of tuberculosis therapy.
  • Daily asthma medication.

 

Findings

Prevention: Pneumococcal Vaccination

Vaccination is a cost-effective strategy for reducing illness and death associated with pneumococcal disease of the lungs (pneumonia) and influenza.

Figure 2.35. Adults age 65 and over who ever received pneumococcal vaccination, 1999-2006

Figure 2.35.  Adults age 65 and over who ever received pneumococcal vaccination, 1999-2006; trend line chart; HP 2010 Target:  90%; percent, 1999, 49.9; 2000, 53.4; 2001, 54.2; 2002, 56.2; 2003, 55.7, 2004, 57, 2005, 56.3; 2006, 57.3.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 1999-2006.

Reference population: Civilian noninstutionalized population age 65 and over.

Note: Age adjusted to the 2000 U.S. standard population.

  • The percentage of adults age 65 and over who ever received a pneumococcal vaccination increased from 49.9% in 1999 to 57.3% in 2006 (Figure 2.35). The Healthy People 2010 target of 90% is unlikely to be met until after 2020 at this rate of change.

Figure 2.36. State variation: Adults age 65 and over who ever received pneumococcal vaccination, 2006

Figure 2.36. State variation: Adults age 65 and over who ever received pneumococcal vaccination, 2006. map of United States. States above average: Washington, Montana, North Dakota, Minnesota, Wisconsin, New Hampshire, Oregon, Wyoming, Nebraska, Kansas, Iowa, Rhode Island, Pennsylvania, Nevada, Colorado, Oklahoma, Mississippi, North Carolina, Massachusetts, Hawaii. States below average, California, Illinois, Alabama, New York, D.C. Average states: Idaho, Utah, South Dakota, Maine, Vermont, Connecticut, New

Key: Above average = rate is significantly above the reporting States average in 2006. Below average = rate is significantly below the reporting States average in 2006.

Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2006.

Reference population: Civilian noninstitutionalized population age 65 and over.

Note: Age adjusted to the 2000 U.S. standard population. "Reporting States average" is the average of all reporting States (51 in this case, including the District of Columbia), which is a separate figure from the national average.

  • In 2006, the reporting States average of adults age 65 and over who had ever received a pneumococcal vaccination was 64.9%, with a range from 52.0% to 74.3%.
  • Twenty Statesxx were significantly above the reporting States average in 2006 (Figure 2.36), with a combined average rate of 70.1%.
  • Four Statesxxi and the District of Columbia were significantly below the reporting States average in 2006, with a combined average rate of 58.5%.
  • Seventeen States showed improvement between 2001 and 2006 in the number of adults age 65 and over who ever received a pneumococcal vaccination.xxii No State showed a significant decrease on this measure during this period (data not shown).

xx The States are Colorado, Hawaii, Iowa, Kansas, Massachusetts, Minnesota, Mississippi, Montana, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Oklahoma, Oregon, Pennsylvania, Rhode Island, Washington, Wisconsin, and Wyoming.
xxi The States are Alabama, California, Illinois and New York.
xxii The States are Florida, Iowa, Kansas, Kentucky, Louisiana, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nebraska, New Hampshire, New Jersey, Ohio, Pennsylvania, South Dakota, and Tennessee.


Treatment: Receipt of Recommended Care for Pneumonia

Recommended care for patients with pneumonia includes receipt of: (1) initial antibiotics within 4 hours of hospital arrival; (2) antibiotics consistent with current recommendations; (3) blood culture before antibiotics are administered; (4) influenza vaccination status assessment/vaccine provision; and (5) pneumonia vaccination status assessment/vaccine provision. The NHQR tracks receipt of this care for each measure and as an overall composite.

Figure 2.37. Hospital patients with pneumonia who received recommended hospital care: Overall composite and five components, 2005 and 2006

Figure 2.37. Hospital patients with pneumonia who received recommended hospital care: Overall composite and five components, 2005 and 2006. bar chart. percent. 2005, Composite, 74.1, Antibiotics within 4 hours, 76.4, Antibiotics selection, 80.4, Blood culture before first antibiotic dose, 82.5, Influenza vaccination status /provision, 56.9, Pneumococcal vaccination status /provision, 62.2, 2006, Composite, 80.4, Antibiotics within 4 hours, 79.7, Antibiotics selection, 85.3, Blood culture before first antibi

Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005 and 2006.

Denominator: Patients hospitalized with a principal diagnosis of pneumonia or a principal diagnosis of either septicemia or respiratory failure and secondary diagnosis of pneumonia.

Note: Beginning in 2005, the data collection method changed from the abstraction of randomly selected medical records for Medicare beneficiaries to the receipt of hospital self-reported data for all payer types.

  • In 2006, 80.4% of adult patients with pneumonia received the recommended care included in the overall pneumonia treatment composite measure (Figure 2.37). This is a significant increase from 2005 (74.1%). For each of the five component measures in 2006, recommended care was received by significantly more patients than in 2005.
  • Among the five components of the composite measure, patients were most likely to receive blood cultures when clinically appropriate (90.0%) and least likely to have their influenza vaccination status assessed and receive the vaccine if indicated (68.1%).
  • Revisions to two component measures applied to data for 2005 that are related to recommended care for pneumonia should be noted:
    • The individual measure of appropriate antibiotic selection for community-acquired pneumonia was changed to exclude patients with health care-associated pneumonia from the denominator used in the calculation.
    • The individual measure for the collection of samples for blood culture within 24 hours of hospital arrival was changed so that only those patients who were admitted to the intensive care unit within 24 hours of hospital arrival are included in the denominator.

Treatment: Receipt of Antibiotics for the Common Cold

Taking antibiotics does not treat or relieve symptoms of the common cold and may lead to the development of antibiotic-resistant bacteria. Although antibiotic prescribing patterns are slowly improving, overuse of antibiotics is still a concern.44 Children have the highest rates of antibiotic use and the highest rates of infection with antibiotic-resistant bacterial pathogens.45

 

Figure 2.38. Visits with antibiotics prescribed for a diagnosis of common cold per 10,000 population, overall and for children under age 18, 1997-2006

Figure 2.38.  Visits with antibiotics prescribed for a diagnosis of common cold per 10,000 population, overall and for children under age 18, 1997-2006. trend line chart. HP 2010 Target for total population: 126.8 per 10,000. Total, all ages, 1997-1998, 220.7, 1999-2000, 164.0, 2001-2002, 172.3, 2003-2004, 142.4, 2005-2006, 90.9, 0-17 years, 1997-1998, 374.8, 1999-2000, 278.1, 2001-2002, 324.7, 2003-2004, 238.9, 2005-2006, 135.5.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 1997-1998, 1999-2000, 2001-2002, 2003-2004, and 2005-2006.

Denominator: U.S. noninstitutionalized population.

  • In 2005-2006, the overall rate of antibiotics prescribed at visits with a diagnosis of the common cold stood at 90.9 per 10,000, which is below the Healthy People 2010 target of 126.8 per 10,000 (Figure 2.38).
  • From 1997-1998 to 2005-2006, the rate of antibiotic prescription at visits with a diagnosis of common cold decreased overall for people of all ages and for children under age 18.

Treatment: Completion of Tuberculosis Therapy

In order to be effective for individuals as well as the public, tuberculosis therapy must be taken to its completion. Failure to complete tuberculosis therapy puts patients at increased risk for treatment failure and for spreading the disease to others. Even worse, it may result in the development of drug-resistant strains of the disease.46

Figure 2.39. Patients with tuberculosis who completed a curative course of treatment within 1 year of initiation of treatment, by age group, 1998-2004

Figure 2.39. Patients with tuberculosis who completed a curative course of treatment within 1 year of initiation of treatment, by age group, 1998-2004. trend line chart. Percent. Total, 1998, 79.1; 1999, 79.9; 2000, 80.2, 2001, 80.5, 2002, 80.9, 2003, 81.5, 2004, 81.9;  Ages 0- 17, 1998, 87.4; 1999, 88.5; 2000, 89.8, 2001, 88.2, 2002, 89.7, 2003, 91.0, 2004, 89.9;  Ages 18-44, 1998, 76.6; 1999, 78.0; 2000, 78.2, 2001, 78.9, 2002, 79.8, 2003, 80.0, 2004, 80.4;  Ages 45-64, 1998, 79.1; 1999, 79.5; 2000, 80.4,

Source: Centers for Disease Control and Prevention, National Tuberculosis Surveillance System, 1998-2004.

Reference population: U.S. civilian noninstitutionalized population.

  • From 1998 to 2004, the rate of completion of tuberculosis therapy within one year did not change significantly for both the total population and all age groups (Figure 2.39).
  • In 2004, children ages 0-17 with tuberculosis were more likely to complete a curative course of treatment within one year of treatment than adults age 18 and over.

Management: Daily Asthma Medication

Improving quality of care for people with asthma can reduce the occurrence of asthma attacks and avoidable hospitalizations. The National Asthma Education and Prevention Program (NAEPP), coordinated by the National Heart, Lung, and Blood Institute, develops and disseminates science-based guidelines for the diagnosis and management of asthma.47 These recommendations are built around four essential components of asthma management critical for effective long-term control of asthma: assessment and monitoring, control of factors contributing to symptom exacerbation, pharmacotherapy, and education for partnership in care.48

Asthma can be effectively controlled over the long term with recommended medications (depending on the severity of the disease), routine checkups, education of patients, and use of asthma management plans.

Figure 2.40. People with current asthma who are now taking preventive medicine daily or almost daily (either oral or inhaler), 2003-2005

Figure 2.40. People with current asthma now taking preventive medicine daily or almost daily (either oral or inhaler), 2003-2005.  trend line chart; percent; Total, 2003, 30.1%, 2004, 30.3%, 2005, 32.2%. Ages 0-17, 2003, 28.5%, 2004, 32.8%, 2005, 30.6%. Ages 18-44, 2003, 21.4%, 2004 20.5%, 2005, 23.1%. Ages 45-64, 2003, 42%, 2004 41.8%, 2005, 40.7%. Ages 65 and over, 2003, 38.7%, 2004 35.6%, 2005, 41%.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2003-2005.

Denominator: Civilian noninstitutionalized population who reported current asthma or an asthma attack within the last 12 months.

  • In 2005, 6.9% of the population had current asthma (reported to still have asthma or have had an episode or attack in the last 12 months; data not shown).
  • Of those with current asthma in 2005, 32.2% reported now taking preventive medicine daily or almost daily (Figure 2.40).
  • People ages 18-44 are less likely than those age 17 and under and age 45 and over to report use of daily preventive medicine for asthma.

 

Nursing Home, Home Health, and Hospice Care

Importance

Type of statisticNumber
Demographics
Number of nursing home residents ever admitted during the calendar year (2006)3,176,11949
Medicare fee-for-service (FFS) admissions for skilled nursing facility (2005)2,543,13350
Number of Medicare FFS home health patients (2006)3,031,81451,xxiii
Number of Medicare FFS beneficiaries using Medicare hospice services (2006)935,56552
Cost
Total costs of nursing home care (2006)$124.9 billion53
Medicare expenditures for nursing home care (2006)$20.8 billion53
Total costs of home health care (2006)$52.7 billion53
Medicare expenditures for home health care (2006)19.8 billion 53
Medicare FFS payments for hospice services (2006)9.2 billion 54

Note: Statistics may vary from previous years due to revised and updated source statistics or addition of data sources. Cost estimates for nursing home and home health services include only costs for freestanding skilled nursing facilities, nursing homes, and home health agencies and not those that are hospital based.

Measures

The NHQR tracks 14 measures of nursing home care. Care is tracked among both short-stay and long-stay residents. Short-stay residents commonly have a brief stay in a nursing home after a hospitalization, which is usually followed by return to their home. Care for short-stay residents is often funded by the Medicare Skilled Nursing Facility benefit. Long-stay residents, in contrast, are expected to stay in the nursing home either permanently or for an extended time. The NHQR also tracks 12 measures for home health care that reflect improvement or deterioration during the course of care. Two core report measures on nursing home care and two core report measures on home health care are highlighted in this section:

  • Use of restraints on long-stay nursing home residents.
  • Presence of pressure sores in short-stay and long-stay nursing home residents.
  • Improvement in ambulation in home health care episodes.
  • Acute care hospitalization of home health care patients.

The NHQR also includes measures of the quality of care provided by hospice organizations. Hospice care is delivered at the end of life to patients with a terminal illness or condition requiring comprehensive medical care as well as psychosocial and spiritual support for the patient and family. The goal of end-of-life care is to achieve a "good death," defined by the Institute of Medicine as one that is "free from avoidable distress and suffering for patients, families, and caregivers; in general accord with the patients' and families' wishes; and reasonably consistent with clinical, cultural, and ethical standards."55

The National Hospice and Palliative Care Organization's Family Evaluation of Hospice Care survey examines the quality of hospice care for dying patients and their family members. Family respondents report how well hospices respect patient wishes, communicate about illness, control symptoms, support dying on one's own terms, and provide family emotional support.56,xxiv

The three noncore measures presented here from the National Hospice and Palliative Care Organization's Family Evaluation of Hospice Care survey are:

  • Receipt of right amount of pain medicine by hospice patients.
  • Receipt of care consistent with patient's stated end-of-life wishes.
  • Referral to hospice at the right time.

xxiii Medicare FFS patients only represent a portion of all home health patients.
xxiv This survey provides unique insight into end-of-life care and captures information about a large percentage of hospice patients but is limited by nonrandom data collection and a response rate of about 40%. Survey questions were answered by family members of patients, who might not be fully aware of the patients' wishes and concerns. These limitations should be considered when interpreting these findings.


 

Findings

Management: Use of Restraints on Long-Stay Nursing Home Residents

A physical restraint is any device, material, or equipment that keeps a resident from moving freely. A resident who is restrained daily can become weak and develop other medical complications. The use of physical and pharmacological restraints can result in a variety of emotional, mental, and physical problems. According to regulations for the nursing home industry, restraints should be used only when medically necessary. Bedrails are not included in this measure because they may be appropriate at night for some patients to prevent falls.

Figure 2.41. Long-stay nursing home residents with physical restraints, 1999-2006

Figure 2.41. Long-stay nursing home residents with physical restraints, 1999-2006. trend line chart. percent. 1999, 10.7, 2000, 10.4, 2001, 10.2, 2002, 9.3, 2003, 7.8, 2004, 7.3, 2005, 6.6, 2006, 6.

Source: Centers for Medicare & Medicaid Services, Minimum Data Set, 1999-2006. Data are from the third quarter of each calendar year.

Denominator: All long-stay residents in Medicare or Medicaid certified nursing home facilities.

Note: Restraint use was determined based on a 7-day assessment period.

  • The overall percentage of long-stay nursing home residents who are physically restrained decreased from 10.7% in 1999 to 6.0% in 2006 (Figure 2.41).
  • The decrease from 6.6 to 6.0 between 2005 and 2006 is also statistically significant.
  • Decreases in the use of physical restraints were observed for all age groups (data not shown) between 1999 and 2006.

Figure 2.42. State variation: Long-stay nursing home residents with physical restraints, 2007

Figure 2.42. State variation: Long-stay nursing home residents with physical restraints, 2007. map of United States. states with lower rate: Alaska, Washington, Montana, Wyoming, North Dakota, Minnesota, Wisconsin, South Dakota, Iowa, Illinois, Nebraska, Kansas, Indiana, Maine, New York, New Hampshire, Vermont, Rhode Island, Connecticut, New Jersey, Pennsylvania, Delaware, Maryland, West Virginia, Virginia, D.C., Texas, Alabama, Hawaii. States with higher rate: California, Utah, New Mexico, Florida, Louisia

Key: Higher rate = State has rate in use of restraints higher than the reporting States average in 2007. Lower rate = State has rate in use of restraints lower than the reporting States average in 2007.

Source: Centers for Medicare & Medicaid Services, Minimum Data Set, Nursing Home Compare, 2007.

Denominator: All long-stay residents in Medicare or Medicaid certified nursing and long-term care facilities.

Note: The "reporting States average" is the average of all reporting States (51 in this case, including the District of Columbia), which is a separate figure from the national average.

  • The reporting States average of use of physical restraints for long-stay residents improved between 2002 and 2007, dropping from 9.7% to 5.1% during this period. There was considerable variation in this measure among States in 2007. States ranged from a low of 1.5% to a high of 11.0% in 2007.
  • Twenty-eight Statesxxv and the District of Columbia outperformed the reporting States average (i.e., less use of physical restraints on long-stay nursing home residents) (Figure 2.42), with a combined average rate of 2.6% in 2007.
  • Thirteen Statesxxvi had rates higher than the reporting States average (i.e., greater use of restraints), with a combined average rate of 8.0% in 2007.
  • In only two States (New Mexico and Utah) did the rate of long-stay nursing home residents with physical restraints not improve from 2002 to 2007 (data not shown). In these States, there was no significant change.

xxv The States are Alabama, Alaska, Connecticut, Delaware, Hawaii, Illinois, Indiana, Iowa, Kansas, Maine, Maryland, Minnesota, Montana, Nebraska, New Hampshire, New Jersey, New York, North Dakota, Pennsylvania, Rhode Island, South Dakota, Texas, Vermont, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.
xxvi The States are Arkansas, California, Florida, Georgia, Louisiana, Mississippi, Missouri, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, and Utah.


Management: Presence of Pressure Sores in Nursing Home Residents

A pressure ulcer, or pressure sore, is an area of broken-down skin caused by sitting or lying in one position for an extended time. Pressure sores can be painful, take a long time to heal, and cause other complications such as skin or bone infections. Pressure sores are classified into four stages (stages 1 through 4, with stage 4 being the most severe) according to the depth or type of tissue damage. The measures presented here include all four stages.

Figure 2.43. Short-stay and long-stay nursing home residents with pressure sores, by type of resident, 1999-2006

Figure 2.43. Short-stay and long-stay nursing home residents with pressure sores, by type of resident, 1999-2006. trend line chart. percent. Short-stay, 1999, 22.4, 2000, 22.6, 2001, 22.0, 2002, 21.6, 2003, 21.7, 2004, 21.2, 2005, 20.7, 2006, 20.1; High-risk, long-stay, 1999, 14.3, 2000, 13.9, 2001, 13.8, 2002, 13.7, 2003, 13.9, 2004, 13.5, 2005, 13.1, 2006, 12.5;  Low-risk, long-stay, 1999, 2.8, 2000, 2.6, 2001, 2.6, 2002, 2.6, 2003, 2.8, 2004, 2.7, 2005, 2.5, 2006, 2.4.

Source: Centers for Medicare & Medicaid Services, Minimum Data Set, 1999-2006.

Denominator: All residents in Medicare or Medicaid certified nursing and long-term care facilities.

  • There were only minor improvements in pressure sore measures for all three types of nursing home residents between 1999 and 2006.
  • From 1999 to 2006, the rate of short-stay residents with pressure sores fell from 22.4% to 20.1% (Figure 2.43).xxvii For high-risk, long-stay residents, the rate fell from 14.3% to 12.5%, and for low-risk, long-stay residents, the rate fell from 2.8% to 2.4%.xxviii
  • For high-risk, long-stay nursing home residents, the decrease from 13.1% in 2005 to 12.5% in 2006 is statistically significant.
  • High-risk, long-stay residents have a fivefold greater risk of having pressure sores than low-risk, long-stay residents.

xxvii "Short-stay" refers to residents who are admitted to a facility and stay fewer than 30 days; these admissions, also referred to as "postacute," typically follow an acute care hospitalization and may involve high-intensity rehabilitation or clinically complex care.
xxviii "Long- stay" (also know as "chronic care") refers to residents who enter a nursing facility typically because they are no longer able to care for themselves at home; they tend to remain in the facility from several months to several years. High-risk residents are those who are in a coma, who do not get or absorb the nutrients they need, or who cannot move or change position on their own. Conversely, low-risk residents can be active, can change positions, and are getting and absorbing the nutrients they need.


Management: Improvement in Ambulation in Home Health Care Episodes

Improvement in ambulation/locomotion is demonstrated by an increase in the percentage of patients who improve walking or mobility with a wheelchair. Many patients receiving home health care may need help to walk safely. This assistance can come from another person or from equipment, such as a cane. Patients who use a wheelchair may have difficulty moving around safely, but if they can perform this activity with little assistance, they are more independent, self-confident, and active. In cases of patients with some neurologic conditions, such as progressive multiple sclerosis or Parkinson's disease, ambulation may not improve even when the home health agency provides good care.

Figure 2.44. Adult home health care patients whose ability to walk or move around improved, by age group, 2002-2006

Figure 2.44. Adult home health care patients whose ability to walk or move around improved, by age group, 2002-2006. trend line chart. percent. Total, 2002, 33.9, 2003, 35.1%, 2004, 37.2%, 2005, 38.8%, 2006, 41.2; Ages 0-64, 2002, 36.2, 2003, 37.4%, 2004, 39.6%, 2005, 40.9%, 2006, 43.1; Ages 65-74, 2002, 37.6, 2003, 38.8%, 2004 41.2%, 2005, 42.9%, 2006, 45.7; Ages 75-84, 2002, 34.1, 2003, 35.4%, 2004 37.5%, 2005, 39.1%, 2006, 41.6; Age 85 and over, 2002, 29.0, 2003, 30.1%, 2004 31.9%, 2005, 33.4%, 2006, 35.

Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set (OASIS), 2002-2006.

Denominator: Episodes for adult nonmaternity patients receiving at least some skilled home health care and not already performing at the highest level according to the OASIS question on ambulation.

  • From 2002 to 2006, the percentage of home health care episodesxxix showing improvement in ambulation/locomotion increased from 33.9% to 41.2% (Figure 2.44).
  • The percentage of home health care episodes showing ambulation/locomotion improvement also increased for every age group.

xxix An "episode" is the time during which a patient is under the direct care of a home health agency. It starts with the beginning/resumption of care and finishes when the patient is discharged or transferred to an inpatient facility. The same patient may be involved in multiple episodes. An episode is a 60-day time period.


Management: Acute Care Hospitalization of Home Health Care Patients

Improvement in acute care hospitalization of home health patients is demonstrated by a decrease in the percentage of patients who had to be admitted to the hospital. Patients may need to go into the hospital while they are getting home health care. Depending on the severity of the patient's condition, this may not be avoidable even with good home health care.

Figure 2.45. Adult home health care patients who were admitted to the hospital, by age group, 2002-2006

Figure 2.45. Adult home health care patients who were admitted to the hospital, by age group, 2002-2006. trend line chart. percent. Total, 2002, 27.7, 2003, 27.8, 2004, 27.9, 2005, 28.0, 2006, 28.3;  0-64, 2002, 34.2, 2003, 34.1, 2004, 34.3, 2005, 34.3, 2006, 34.6. 65-74, 2002, 27.2, 2003, 27.3, 2004, 27.4, 2005, 27.3, 2006, 27.5; 75-84, 2002, 26.3, 2003, 26.4, 2004, 26.6, 2005, 26.6, 2006, 27; 85+, 2002, 26.3, 2003, 26.4, 2004, 26.3, 2005, 26.5, 2006, 26.7.

Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set (OASIS), 2002-2006.

Denominator: Episodes for adult nonmaternity patients receiving at least some skilled home health care.

  • In 2006, 28.3% of home health care episodes ended in hospitalization (Figure 2.45).
  • Between 2002 and 2006, the rate did not improve for the entire population or for any age group.
  • In all 5 data years, home health care patients under age 65 years were more likely than patients ages 65-74 to require hospitalization. This may be because home health care patients under age 65 in Medicare tend to have different characteristics, such as greater degrees of disability and illness.

Figure 2.46. State variation: Adult home health care patients who were admitted to the hospital, 2007

Figure 2.46. State variation: Adult home health care patients who were admitted to the hospital, 2007. map of United States. Lower rate: Washington, Oregon, California, Idaho, Nevada, Alaska, Hawaii, Montana, Wyoming, Utah, Arizona, New Mexico, Colorado, North Dakota, South Dakota, Nebraska, Kansas, Missouri, Wisconsin, Michigan, Maine, Pennsylvania, New Jersey, Delaware, Maryland, West Virginia, Virginia, D.C. Georgia, Florida. Higher rate: Iowa, Oklahoma, Texas, Arkansas, Louisiana, Indiana, Ohio, Kentuck

Key: Higher rate = State has rate of hospitalizations higher than the reporting States average in 2007. Lower rate = State has rate of hospitalizations lower than the reporting States average in 2007.

Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set (OASIS), 2007.

Denominator: Episodes for adult nonmaternity patients receiving at least some skilled home health care.

Note: The "reporting States average" is the average of all reporting States (51 in this case, including the District of Columbia), which is a separate figure from the national average.

  • In 2007, the reporting States average for home health care patients who were admitted to the hospital was 31.9%.
  • Thirteen Statesxxx were significantly above the reporting States average in 2007 (Figure 2.46), with a combined average rate of 37.0%.
  • Twenty-nine Statesxxxi and the District of Columbia were significantly below the reporting States average in 2007, with a combined average rate of 25.9%.

xxx The States are Arkansas, Connecticut, Indiana, Iowa, Kentucky, Louisiana, Massachusetts, Mississippi, New York, Ohio, Oklahoma, Tennessee, and Texas.
xxxi The States are Alaska, Arizona, California, Colorado, Delaware, Florida, Georgia, Hawaii, Idaho, Kansas, Maine, Maryland, Michigan, Missouri, Montana, Nebraska, Nevada, New Jersey, New Mexico, North Dakota, Oregon, Pennsylvania, South Dakota, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.


Management: Receipt of Right Amount of Pain Medicine by Hospice Patients

Addressing the comfort aspects of care, such as relief from pain, fatigue, and nausea, is an important component of hospice care.xxxii

 

Figure 2.47. Hospice patients who did NOT receive the right amount of medicine for pain, by age group, 2005-2007

Figure 2.47. Hospice patients who did NOT receive the right amount of medicine for pain, by age group, 2005-2007. bar chart. percent. Total, 2005, 5.9, 2006, 5.8, 2007, 5.7; 18-44, 2005, 8.3, 2006, 7.8, 2007, 8.5; 45-64, 2005, 6.2, 2006, 6.2, 2007, 6.0; 65 plus, 2005, 4.9, 2006, 5.0, 2007, 5.0.

Source: National Hospice and Palliative Care Organization, Family Evaluation of Hospice Care, 2005-2007.

Denominator: Adult hospice patients.

  • The percentage of hospice patients whose families reported that they did not receive the right amount of medicine for pain was 5.7% in 2007 (Figure 2.47).
  • Families of hospice patients ages 18-44 and ages 45-64 were more likely to report that the patient did not receive the right amount of pain medicine (8.5% and 6.0%, respectively) in 2007 compared with families of patients age 65 and over (5.0%).
  • Between 2005 and 2007, the percentage of hospice patients whose families reported that they did not receive the right amount of medicine for pain did not change significantly overall or for any adult age group (18-44, 45-64, 65 and over).

xxxii This measure is based on responses from a family member of the deceased. In interpreting it, it should be noted that family members may or may not be able to determine whether the right amount of medicine for pain was administered.


Management: Receipt of Care Consistent With Patient's Stated End-of-Life Wishes

End-of-life care should respect a patient's stated end-of-life wishes. This includes shared communication and decisionmaking between providers and hospice patients and their family members and respect for cultural beliefs.

Figure 2.48. Hospice patients age 18 and over who did NOT receive care consistent with their stated end-of-life wishes, by age group, 2005-2007

Figure 2.48. Hospice patients age 18 and over who did NOT receive care consistent with their stated end-of-life wishes, by age group, 2005-2007. bar chart. percent. Total, 2005, 5.5, 2006, 5.5, 2007, 5.6; 18-44, 2005, 6.7, 2006, 7.7, 2007, 7.2; 45-64, 2005, 5.0, 2006, 5.1, 2007, 5.3; 65 plus, 2005, 5.6, 2006, 5.3, 2007, 5.6.

Source: National Hospice and Palliative Care Organization, Family Evaluation of Hospice Care, 2005-2007.

Denominator: Adult hospice patients.

  • The percentage of hospice patients whose families reported that they did not receive end-of-life care consistent with their stated wishes was 5.6% in 2007 (Figure 2.48).
  • In 2007, hospice patients ages 18-44 were less likely than patients ages 45 and over to receive end-of-life care consistent with their wishes.
  • Between 2005 and 2007, the percentage of hospice patients whose families reported that they did not receive end-of-life care consistent with their stated wishes did not change significantly overall or for any adult age group (18-44, 45-64, 65 and over).

Management: Referral to Hospice at the Right Time

Caregivers' perception of the timing of the referral to hospice is often associated with increased reports of unmet needs and lower satisfaction with hospice care. The perception of referral timing may be an indicator of adequacy of access to hospice care.

Figure 2.49. Hospice patient caregivers who perceived patient was NOT referred to hospice at the right time, by age group, 2005-2007

Figure 2.49. Hospice patient caregivers who perceived patient was NOT referred to hospice at the right time, by age group, 2005-2007. bar chart. percent. Total, 2005, 12.7, 2006, 12.1, 2007, 11.3; 18-44, 2005, 16.8, 2006, 16.8, 2007, 15.5; 45-64, 2005, 14.1, 2006, 13.7, 2007, 13.0; 65 plus, 2005, 10.2, 2006, 9.6, 2007, 9.1.

Source: National Hospice and Palliative Care Organization, Family Evaluation of Hospice Care, 2005-2007.

Denominator: Adult hospice patients.

Note: Caregivers were family members who interacted with hospice providers.

  • The percentage of hospice patient caregivers who perceived that the patient was not referred to hospice at the right time was 11.3% in 2007 (Figure 2.49).
  • In 2007, overall, and for all three patient age groups, caregivers' perception of referral to hospice at the right time improved from 2005.
  • In 2007, caregivers for the 65 and over age group were less likely to report a perception that the patient was not referred at the right time than caregivers for either the 18-44 or 45-64 age group.
  • Caregivers for the 45-64 age group were less likely than caregivers for the 18-44 age group to report a perception that the patient was not referred at the right time.
Current as of March 2009
Internet Citation: Chapter 2. Effectiveness (continued, 3): National Healthcare Quality Report, 2008. March 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhqr08/Chap2c.html