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Medicare and privately insured patients are likely to
pay more than others for similar home health services
The home health industry has grown tremendously over the past decade, with expenditures for
these services increasing from $5.6 billion in 1985 to almost $25 billion in 1993. Nearly two-thirds
of home health patients have Medicare as their primary source of payment; about 10 percent of
patients have either private insurance or pay out of pocket. According to a recent study by the
Agency for Health Care Policy and Research, Medicare and private insurers may pay more than
other payors for such services.
Former AHCPR staff members Vicki A. Freedman, Ph.D., (currently with RAND) and James D.
Reschovsky, Ph.D., (currently with the Center for Studying Health System Change) used the 1992
National Home and Hospice Care Survey to compare the average charge for a Medicare home
health visit to the average charge for patients with other sources of payment. They found that on
average, home health patients were charged $75 per visit by home health care agencies in 1992.
Those covered by Medicare were charged an average of $80 per visit, about $10 more than
Medicaid patients, $19 more than patients paying out-of-pocket, and twice as much as patients
with other primary sources of payment. Patients with private insurance were charged an average
of $88. Differences between Medicare beneficiaries and the privately insured were small (about 6
percent) and not significant. These differences persisted even after controlling for disparities
across payors in mix of home health services and agency characteristics.
Charges do not generally correspond to actual reimbursement, especially for Medicare and
Medicaid. Medicare pays the lower of cost ceilings or charges. For Medicaid, incentives for
charge-setting vary by State depending on the reimbursement system.
In 1992, charges by home health agencies for Medicare beneficiaries exceeded actual payments to
those agencies by 25 percent. Although this research analyzes charges, not payments, the findings
suggest that Medicare and private pay insurers may be paying more than other payors for the
For details, see "Differences across payors in charges for agency-based home health services:
Evidence from the national home and hospice care survey," by Drs. Freedman and Reschovsky, in
the October 1997 Health Services Research 32(4), pp. 433-452. Reprints (AHCPR
No. 98-R021) are available from the AHCPR Publications
Rural residents are more likely than city-dwellers to
be without health insurance for longer periods
About 40 million Americans are without health insurance coverage. Spells of uninsurance have
increased in length for all citizens, particularly rural residents. Clearly, uninsured individuals do
visit their physicians less often than those with insurance. However, when urban residents finally
obtain health insurance, the number of physician visits actually declines. Rural residents, on the
other hand, visit the doctor as often or as little as when they had no insurance, according to a
study supported by the Agency for Health Care Policy and Research (HS05760).
Keith J. Mueller, Ph.D., of the University of Nebraska Medical Center, and his colleagues
examined the relationship between insurance status and number of physician visits from 1989 to
1993. They also looked at spells of uninsurance among a sample of 1,235 Nebraska residents who
were interviewed in 1992 and were asked about their insurance status for the previous 5 years.
The researchers found that the median length of uninsurance spells was 14 months, with
three-fourths of the spells lasting at least 6 months and one-fourth lasting longer than 34 months.
Median uninsurance spells were about three times longer among rural (16 months) and frontier
(22 months) residents compared with their urban neighbors (6 months), who are more apt to have
Urban residents actually recorded more physician visits at the end of a spell of uninsurance than at
the beginning of the next spell of insurance. For rural and frontier residents, the pattern was
reversed. Frontier county residents changed from an average of 0.16 physician visits in the 3
months ending a spell of uninsurance to an average of 0.43 visits in the first 3 months of having
insurance. The difference was less dramatic among non-frontier rural residents, but it was in the
same direction. Urban residents may have increased physician visits at the end of an uninsured
spell because of availability of free clinics and the prospect of copayments or a deductible with
insurance, or it may be in anticipation of preexisting condition clauses in the insurance plans.
Rural residents had longer spells of uninsurance and hence a greater likelihood of pent-up
demand. Also, they are more likely not to seek physician services when they cannot pay, both
because of pride and because of limited opportunities for free clinic care, notes Dr. Mueller.
More details are in "Lengthening spells of uninsurance and their consequences," by Dr. Mueller,
Kashinath Patil, Ph.D., and Fred Ullrich, in the Winter 1997 issue of The Journal of Rural
13(1), pp. 29-37.
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Low-risk elderly patients may be safely discharged
early from the hospital following bypass surgery
In the wake of cost-cutting efforts, more patients are being discharged from the hospital within 5
days of coronary artery bypass graft (CABG) surgery. This has raised concerns that such early
discharges may compromise quality of care, particularly for elderly patients. However, a recent
study supported by the Agency for Health Care Policy and Research (HS06503 and HS08805)
suggests that low-risk elderly CABG patients may be able to be safely discharged within 5 days of
surgery. In particular, it showed that early discharge did not raise the risk of short-term (60-day)
mortality or readmission among elderly CABG patients.
The Ischemic Heart Disease Patient Outcomes Research Team (PORT), supported by AHCPR
and led by Elizabeth R. DeLong, Ph.D., of Duke University, used Medicare discharge data from
the 1992 National Claims History File to examine the prevalence of early discharge (postsurgical
hospital stay of 5 days or less) among 83,347 non-HMO Medicare patients who underwent
CABG in the United States in 1992. Most patients were white (94 percent) and male (68 percent),
with an average age of 72 years. The researchers identified patient characteristics associated with
early discharge and obtained rates of readmission or death for postoperative stays between 4 and
In 1992, 6 percent of Medicare CABG patients were discharged within 5 days of the operation.
But the prevalence of early discharge varied considerably among States, ranging from 1 percent to
21 percent. Patients discharged early tended to be younger and male and have fewer coexisting
illnesses. They also had the lowest rates of death and hospital readmission and lower odds of
experiencing an adverse outcome relative to patients with average postoperative stays. This
suggests that physicians were able to identify low-risk candidates for early discharge and that
higher rates of early discharge might be safely achieved, conclude the researchers.
For more information, see "Impact of early discharge after coronary artery bypass graft surgery
on rates of hospital readmission and death," by Patricia A. Cowper, Ph.D., Eric D. Peterson,
M.D., M.P.H., Dr. DeLong, and others, in the October 1997 Journal of the American College
Cardiology 30, pp. 908- 913.
Occupational therapy may reduce health declines in
Individualized occupational therapy (OT) that focuses on development of needed skills to cope
with everyday activities—such as healthful shopping and mastering the local public
system—may be the answer for many older, independent-living adults who want to improve
quality of life, psychological well-being, and overall health. According to a recent study,
preventive health programs based on individualized OT may mitigate against the health risks of
older adults. The study was supported by a joint agreement between the National Institute on
Aging and the Agency for Health Care Policy and Research (AG11810).
The study's findings show that older adults need more than social activity or arts and crafts, notes
Florence Clark, Ph.D., of the University of Southern California. Dr. Clark and her colleagues
randomly assigned 361 culturally diverse men and women 60 years of age and older to one of
three groups: occupational therapy, social activities, and no intervention. The subjects included
residents living in one of two Government-subsidized apartment complexes for independent-living
older adults and residents living in nearby private homes who used the complexes' senior centers.
The OT sessions included 2 hours of group OT a week and 9 total hours of individual OT during
the 9-month study period. The sessions showed adults with limited income and resources how to
select and perform activities, such as grooming and exercising, to achieve a healthy and satisfying
lifestyle. The social activities ranged from community outings and dances to craft projects.
Persons who received OT ranked higher on a life satisfaction index, health perception survey, and
seven of eight health status survey scales that measured items ranging from bodily pain and social
functioning to general mental health. Also, individuals in the OT group that had certain medical
problems tended to improve or decline less severely over time than those in the social activity and
nontreatment control groups, who tended to decline over time. The finding that only 5 of 15
outcome measures failed to demonstrate a significant gain for the OT group relative to the control
groups provides solid evidence of the positive effects of OT, according to the researchers. They
attribute the success of the OT program to its focus on meaningful and health-promoting activities
and to its individual tailoring.
See "Occupational therapy for independent-living older adults," by Dr. Clark, Stanley P. Azen,
Ph.D., Ruth Zemke, Ph.D., O.T.R., and others, in the October 22, 1997, Journal of the
Medical Association 278(16), pp. 1321-1326.
Researchers examine use of health care networks by
The long-term care networks used by the elderly vary by factors such as race, residence, and age.
Two recent studies, led by University of Florida researchers Julie K. Netzer, Ph.D., and Chuck W.
Peek, Ph.D., and supported in part by the Agency for Health Care Policy and Research (National
Research Service Award fellowships F32 HS00086 and F32 HS00088), identify some of these
The first study (HS00086 and HS00088) shows that race has a significant effect on the use of
community-based services but not use of in-home services. The second study (HS00086)
demonstrates that once elderly persons activate the caregiving network, it undergoes many
changes in type and source of care over time.
Netzer, J.K., Coward, R.T., Peek, C.W., and others (1997, September). "Race and residence
differences in the use of formal services by older adults." Research on Aging 19(3), pp. 300-332.
Black elders, especially rural blacks, are more likely to use community-based services than other
elderly adults, concludes this study. It shows, for instance, that black rural elders had the highest
rate of using senior centers; nearly one-third of these elders (30 percent) reported attending a
senior center. Also, older blacks were nearly four times as likely as older whites to report using
special transportation services (12.4 percent vs. 3.5 percent). In urban settings, the odds of older
blacks using senior centers were more than twice as high as for their white counterparts. And in
rural areas, older blacks were five times more apt to use these centers than their white neighbors.
Black rural elders in this study were more likely than whites to emphasize the value of formal
community-based services in improving the quality of their lives than white elders living in the
same communities. Location of the community-based services also played a role. The only senior
center in several of the rural sites studied was located in the black community and staffed
predominantly by blacks. Blacks in these communities expressed strong positive attitudes about
the senior center and special transportation services. Whites, on the other hand, reported feeling
uncomfortable about attending mainly black senior centers or using special transportation used
primarily by blacks. Instead, elderly whites may rely more extensively on church groups,
grandmothers' clubs, relatives, and friends for the help they need, explain the researchers.
They used data from a longitudinal study of race and residence differences in the use of long-term
care among 1,200 community-dwelling adults 65 years of age and older and living in one of four
North Florida counties that include a range of residential contexts (i.e., a large city, several small
towns, and rural farming areas). They examined use of two community-based services (senior
centers and special transportation services for senior citizens) and two home-based services
(homemaker and nursing care). Analysis revealed no racial differences in use of homemaker
services or home health services. However, rural elders were more apt than urban elders to use
both services (9.3 percent and 8.6 percent vs. 3.7 percent and 5.4 percent, respectively).
Peek, C.W., Zsembik, B.A., and Coward, R.T. (1997, September). "The changing caregiving
networks of older adults." Research on Aging 19(3), pp. 333-361.
More than 70 percent of elderly persons who begin a 2-year period with no help needed for daily
living tasks, ranging from eating and dressing to shopping and housework, remain independent of
the care of others at the end of that time. Once they activate caregiving networks, they tend to
continue to use them for substantial periods of time, concludes this study. It shows, for example,
that among the elderly who began an interval receiving exclusively informal care (unpaid care,
usually from family members), 44 percent still had only informal caregivers, and 19 percent had no
help from others 2 years later. Conversely, 15 percent of elderly individuals who began a period
receiving only informal care needed more care within 2 years: 11 percent added a formal (paid)
care provider, and nearly 5 percent were receiving institutional care by the end of 2 years.
Of elderly persons who began a period with only formal help, 38 percent continued to receive
only formal help at the end of 2 years, and 19 percent ended the time period with no helpers.
Nearly 15 percent added an informal helper, while 3 percent received institutional care. About
one-third (34 percent) of those who entered a period receiving mixed care (formal and informal
help) remained in that state 2 years later. This suggests that mixed care is not simply a transitory
response to a health crisis, and that a significant number of elders receive intensive
community-based care from both formal and informal sources on a long-term basis.
Older adults whose caregiving network contained both formal and informal care appear to be
among the most frail elderly in this study. For instance, 30 percent had died and 11 percent were
residing in a nursing home 2 years later. Similarly, 93 percent of those who began an interval in a
nursing home either continued to receive institutional care or had died by end of the interval. As
the sample aged, the proportions receiving formal help and mixed help rose steadily, as did the
proportion of those residing in a nursing home. These findings are based on examination of data
from the nationally representative Longitudinal Study of Aging (LSOA) from 1984 to 1990 to
describe the changes adults 70 years of age and older experience in their caregiving arrangements
More than half of nursing home residents have
Some nursing home residents have behavior problems. They cry for long spells, get lost or wander
the halls, yell at or physically hurt others, steal things, or have hallucinations or delusions. In
1987, over half (54 percent) of U.S. nursing home residents had some type of behavior problem.
Certain mental and physical disabilities, as well as personal characteristics, increase the likelihood
that a nursing home resident will have behavioral problems, concludes William D. Spector, Ph.D.,
of the Center for Organization and Delivery Studies, Agency for Health Care Policy and
Dr. Spector and his colleagues Mary E. Jackson, Ph.D., of the MEDSTAT Group, and Peter V.
Rabins, M.D., of Johns Hopkins University, used the Institutional Population Component of the
1987 National Medical Expenditure Survey (NMES)—a national sample of the
elderly—or the study. They analyzed the data to identify which factors correlated with four
of behaviors: delusions/hallucinations, aggressive behaviors, collecting behaviors (hoarding and
stealing), and wandering or inability to avoid dangers.
Cognitive impairment, dependencies in activities of daily living (ADLs; e.g., eating, dressing,
bathing, using the toilet, etc.), incontinence, a history of psychiatric problems, difficulty
understanding oral communications, and vision problems were associated with a higher likelihood
of exhibiting disruptive behaviors. Being unable to walk decreased the likelihood of behavior
problems, presumably because of increased isolation. The patterns of association varied by type of
disruptive behavior. Men were found to be more at risk for aggressive behaviors than women,
who were more at risk for delusions and hallucinations. Generally, cognitive impairment,
schizophrenia, and other psychoses had a greater impact for almost all behavior types. Impairment
in receptive communication (understanding what is said) was a risk factor for all behaviors but
had a more moderate impact. Incontinence and ADL dependencies, in general, had less impact
and affected fewer behaviors.
For details, see "Risk of behavior problems among nursing home residents in the United States,"
by Drs. Jackson, Spector, and Rabins in the November 1997 Journal of Aging and Health
pp. 451-472. Reprints (AHCPR Publication No. 98-R011) are available from the AHCPR
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Interactive computer game encourages adolescents to
An interactive computer program can encourage adolescents to delay parenthood, according to a
study supported in part by the Agency for Health Care Policy and Research (HS07399). It shows
that teenagers who used the program knew more about the costs of having a child and were
significantly more apt to value contraception, view a child as adding problems to a teen's life, and
want to delay parenthood. Also, 91 percent of teens said they would play the game again and
would recommend it to a friend. The program was developed as part of the Harlem Hospital
Adolescent Pregnancy Prevention Project.
In this paper, researchers at Columbia University School of Public Health and Harlem Hospital
Center use the computer program as an example of four phases of a community-based public
health program model for research: preresearch, research, transition phases, and full
institutionalization. They point out that coalition-building was critical in the preresearch phase to
share responsibility for conceptualizing and implementing the project. In this case, the team
included physicians, social workers, labor and school representatives, librarians, and emergency
medical services personnel. Workshops covered themes selected by the adolescents: education
and careers, sexuality, AIDS, and teen advocacy. Over a 2-year period, 24 different groups
participated in interactive presentations engaging 250 adolescents. The researchers distributed a
flier and offered the program in the outpatient clinic and on the adolescent ward of Harlem
Acceptance by teens was crucial and set the stage for the transition phase to making the program
a long-term community resource. The researchers sought continued funding and staffing from
institutions to embed the project within existing programs, and they maintained community
linkages. Also critical to the transition phase was the extensive outreach effort conducted as part
of the project, including two major conferences held at a school and another at the hospital, which
featured the computer game but also addressed a whole range of adolescent life issues. As a result
of the success of these events, an alternative high school for pregnant teens became an additional
Details are in "A community research model: A challenge to public health," by Pamela
Brown-Peterside, Ph.D., and Danielle Laraque, M.D., in the September 1997 American
of Public Health 87(9), pp. 1563-1564.
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Use of hormone replacement therapy among women
without menopausal symptoms has doubled, but still
Although menopausal symptoms such as hot flashes and headaches are the most common clinical
indication for hormone replacement therapy (HRT), there is growing awareness of the ability of
HRT to reduce the risk of osteoporosis and heart disease in postmenopausal women. The number
of postmenopausal women without menopausal symptoms who reported use of HRT doubled
from 3 percent in 1989 to nearly 7 percent in 1993 and 1994. HRT use rates for women with
symptoms stayed about the same (40 percent to 38 percent).
Use rates varied by physician specialty, patient characteristics, and region. Primary care physicians
other than obstetrician/gynecologists (Ob-Gyns) continued to prescribe HRT at a low rate (4 to 7
percent of visits by postmenopausal women, compared with 23 percent of similar visits to
Ob-Gyns), according to a study supported by the Agency for Health Care Policy and Research
(HS07892). These low use rates and substantial HRT practice variations suggest missed
opportunities to improve the health of patients, conclude the Harvard Medical School researchers
who conducted the study.
The investigators analyzed a nationally representative sample of 6,341 office visits by women 40
years of age and older to primary care physicians using the 1993 and 1994 National Ambulatory
Medical Care Surveys to identify independent predictors of estrogen use and evaluate time trends
from 1989 through 1994. Nearly 5 percent of women visiting the doctor in 1989 and 1990
reported use of HRT; this figure grew to 8 percent in 1993 and 1994. Although this increase in
the use of HRT was confined to asymptomatic women, menopausal symptoms continued to be the
primary determinant of HRT use. In 1993-1994, women with menopausal symptoms were six
times more likely than asymptomatic women to receive HRT.
Physicians did not seem inclined to prescribe HRT to prevent heart disease, but did seem inclined
to prescribe it to prevent complications from osteoporosis or hyperlipidemia (high blood fat
levels). Fewer or a similar number of women with risk factors for heart disease such as
hypertension, a smoking habit, obesity, and diabetes mellitus, or with known coronary heart
disease used HRT compared with women who did not have these risk factors. However, more
women with osteoporosis or hyperlipidemia used HRT than women without these conditions (10
percent vs. 8 percent and 11 percent vs. 8 percent, respectively).
Details are in "Low rates of hormone replacement in visits to United States primary care
physicians," by Randall S. Stafford, M.D., Ph.D., Demet Saglam, M.A., Nancyanne Causino,
Ed.D., and David Blumenthal, M.D., M.P.P., in the American Journal of Obstetrics and
Gynecology 177(2), pp. 381-387, 1997.
Head injury patients who develop late seizures are
candidates for anticonvulsant medicine
People who suffer severe head injury commonly have posttraumatic seizures that can occur
shortly after the injury to months or even years later. When late seizures develop (i.e., 7 days after
the injury), the probability of having another seizure is high, finds a recent study supported in part
by the Agency for Health Care Policy and Research (HS06497). Patients should be treated
aggressively with anticonvulsant medication after an initial unprovoked late seizure, recommends
Sureyya S. Dikmen, Ph.D.
Dr. Dikmen and her University of Washington colleagues conducted a
longitudinal study of 63 moderately to severely head-injured adults who developed late
posttraumatic seizures. The subjects suffered the seizures while participating in a randomized,
placebo-controlled study of the effectiveness of phenytoin to prevent posttraumatic seizures. The
researchers measured the time from the first unprovoked late seizure to time of seizure recurrence
and found that 86 percent of patients experienced more late seizures within 2 years. Of the
patients studied, there was a 47 percent chance of having another unprovoked seizure within 1
month of the first late seizure. The incidence of recurrence was 69 percent by 6 months, 82
percent by 1 year, and 86 percent by 2 years. The frequency of recurrent seizures varied
considerably: 52 percent of patients experienced at least 5 late seizures and 37 percent had 10 or
more late seizures within the 2-year period.
The risk of having another seizure after the initial late seizure was significantly greater for persons
whose head injuries were characterized by a depressed skull fracture or an acute subdural
hematoma (accumulation of blood next to the brain). The risk of having five or more late seizures
was greatest for those having prolonged coma (longer than 7 days). Most patients in this study
suffered from closed head injuries and were treated with anticonvulsant medication after their first
late seizure. Without medication, the seizures might have recurred earlier and been more frequent
and severe, note the researchers. They point out the need to study newer anticonvulsant drugs for
efficacy in controlling recurrent seizures in this high-risk population.
For more information, see "Risk of seizure recurrence after the first late posttraumatic seizure,"
by Alan M. Haltiner, Ph.D., Nancy R. Temkin, Ph.D., and Dr. Dikmen, in the Archives of
Medicine and Rehabilitation 78, pp. 835-840, 1997.
Sociodemographic and clinical factors affect use of
diagnostic imaging tests for patients with back pain
One of the major costs associated with the $24 billion in health care expenditures in 1990 for low
back problems is use of expensive diagnostic imaging procedures such as magnetic resonance
imaging (MRI), noncontrast computed tomography (CT), and CT-myelography. It has been
suggested that these imaging tests are often used inappropriately for patients who do not have
clinical symptoms to warrant their use.
A recent study compared the actual use of diagnostic imaging tests for persistent low back pain
with the recommendations set forth in the clinical practice guideline on low back pain, which was
developed with support from the Agency for Health Care Policy and Research and released by
AHCPR in 1994. The study, conducted by Stacey J. Ackerman, M.S.E., Ph.D., and colleagues at
Johns Hopkins University, analyzed use of diagnostic imaging examinations in 2,374 patients with
persistent low back problems who were enrolled in the National Low Back Pain Study from 1986
Patients who underwent MRI were distinguished from those who received only lumbosacral spine
x-rays by more physician visits in the preceding 12 months, more functional impairment, presence
of sciatica, and presence of neurologic signs/symptoms suggestive of nerve root compromise, as
well as higher socioeconomic status. Those who underwent MRI had suspected soft tissue
involvement; suspected structural involvement characterized those who received noncontrast CT.
These findings represent the first indication that actual practice may be reasonably close to the
guideline recommendations, according to the researchers.
Persons who underwent both MRI and CT-myelography were distinguished from those who
received only CT-myelography only by nonclinical factors, such as higher annual household
income, disability compensation, and male sex. Patients eligible for disability compensation may
have complained of more severe or persistent symptoms, simply had coverage for two advanced
imaging tests, or needed both tests to obtain disability compensation. These findings suggest that
nonclinical factors, such as socioeconomic characteristics and patient preferences, play a
substantial role in the diagnostic imaging decision. Nevertheless, the use of tests in this study
closely followed clinical indications for their use recommended by the AHCPR-supported
See "Patient characteristics associated with diagnostic imaging evaluation of persistent low back
problems," by Dr. Ackerman, Earl P. Steinberg, M.D., M.P.P., R. Nick Bryan, M.D., Ph.D., and
others, in Spine 22(14), pp. 1634-1641, 1997.
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