Series 13, Number 161 June 2006

Use of Computerized

Medical Records in Home

Health and Hospice

Agencies: United States,

2000
Copyright information

All material appearing in this report is in the public domain and may be

reproduced or copied without permission; citation as to source, however, is

appreciated.

Suggested citation

Pearson WS, Bercovitz AR. Use of computerized medical records in home

health and hospice agencies: United States, 2000. National Center for Health

Statistics. Vital Health Stat 13(161). 2006.

Library of Congress Catalog Card Number 97-10617

Use of computerized medical records in home health and hospice agencies :

United States, 2000.

p. ; cm.— (DHHS publication ; no. (PHS) 2006–1732) (Vital and health

statistics. Series 13, Data from the National Health Care Survey ; no. 161)

‘‘July 2006.’’

Includes bibliographical references.

ISBN 0–8406-0609–5

1. Medical records—Data processing. 2. Home care services. 3. Hospice

care. I. National Center for Health Statistics (U.S.). II. National Health Care

Survey (U.S.). III. Series. IV. Series: Vital and health statistics. Series 13, Data

from the National Health Survey ; no. 161.

[DNLM: 1. Medical Records Systems, Computerized—statistics & numerical

data—United States. 2. Home Care Agencies—statistics & numerical data—

United States. 3. Hospices—statistics & numerical data—United States.

W2 A N148vm no.161 2006]

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Series 13, Number 161

Use of Computerized Medical

Records in Home Health and

Hospice Agencies: United States,

2000

Data From the National Health Care

Survey

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

Hyattsville, Maryland

June 2006

DHHS Publication No. (PHS) 2006-1732
National Center for Health Statistics

Edward J. Sondik, Ph.D., Director

Jennifer H. Madans, Ph.D., Acting Co-Deputy Director

Michael H. Sadagursky, Acting Co-Deputy Director

Jennifer H. Madans, Ph.D., Associate Director for Science

Edward L. Hunter, Associate Director for Planning, Budget,

and Legislation

Michael H. Sadagursky, Associate Director for

Management and Operations

Lawrence H. Cox, Ph.D., Associate Director for Research

and Methodology

Margot A. Palmer, Director for Information Technology

Margot A. Palmer, Acting Director for Information Services

Linda T. Bilheimer, Ph.D., Associate Director for Analysis,

Epidemiology, and Health Promotion

Charles J. Rothwell, M.S., Director for Vital Statistics

Jane E. Sisk, Ph.D., Director for Health Care Statistics

Jane F. Gentleman, Ph.D., Director for Health Interview

Statistics

Clifford L. Johnson, Director for Health and Nutrition

Examination Surveys

Division of Health Care Statistics

Jane E. Sisk, Ph.D., Director

Robin E. Remsburg, Ph.D., Deputy Director

Irma Arispe, Ph.D., Associate Director for Science

Robin E. Remsburg, Ph.D., Acting Chief, Long-Term Care

Statistics Branch
Contents

Abstract ................................................................................................. 1

Introduction .............................................................................................. 1

Highlights................................................................................................ 2

Methods ................................................................................................. 2

Results .................................................................................................. 3

Overall Use of CMRs .................................................................................... 3

Characteristics of All Agencies............................................................................. 3

Characteristics of Home Health Service Agencies.............................................................. 3

Summary and Discussion ................................................................................... 4

References ............................................................................................... 5

Appendix I............................................................................................... 8

Technical Notes ......................................................................................... 8

Appendix II .............................................................................................. 10

Agency Questionnaire .................................................................................... 10

Figure

1. Percent distribution of home health and hospice agencies currently using, or planning to use within the next year, a

computerized medical record: United States, 2001......................................................... 3

Detailed Tables

1. Weighted number and percent of agencies using a computerized medical record (with standard error), by agency type:

United States, 2000.................................................................................. 6

2. Percent distribution of agencies using a computerized medical record (with standard error), by selected agency

characteristics: United States, 2000 ..................................................................... 6

3. Percent distribution of agencies delivering home health services that use a computerized medical record (with

standard error), by selected agency characteristics: United States, 2000........................................ 7

iii
Objective

The use of information technology (IT),

such as computerized medical records

(CMR), has been proposed as a method

for increasing the efficiency of delivered

services, raising the level of the quality of

care provided, and decreasing the number

of medical errors. Research on IT and

CMRs in health care has focused primarily

on hospitals and physicians’ offices, and

there currently exists no nationally

representative information for home health

and hospice agencies. This report

provides the first nationally representative

estimates of the prevalence of CMR use

in home health and hospice agencies in

the United States in 2000.

Methods

Data are from the 2000 National

Home and Hospice Care Survey. Data

presented include estimates of home

health and hospice agencies that are

currently using or planning to use a CMR

in the next year. CMR use is also

presented by agency characteristics.

Results and Conclusions

Approximately 32% of all agencies

were using a CMR. Nearly one-third of

home health agencies (32.1%), one-fifth

of hospice agencies (18.6%), and

two-fifths of mixed-type agencies (offering

both services) (40.3%) reported using a

CMR.

Number of current active patients

and provision of ‘‘high technology’’

services (e.g., respiratory, intravenous,

or enterostomal therapy) were

significantly associated with use of

CMRs. While 23.0% of agencies with

50 or fewer patients reported use of a

CMR, the proportion almost doubled to

44.8%, among agencies with 100 or

more patients. Over one-third (34.8%)

of agencies that provided high

technology services reported using a

CMR, compared with one-fifth (20.8%)

of agencies that did not provide high

technology services. No other agency

characteristics were found to have a

significant relationship with CMR use.

Keywords: National Home and

Hospice Care Survey c Home Health

Agencies c Hospice Agencies c

information technology c computerized

medical records

Use of Computerized Medical

Records in Home Health and

Hospice Agencies: United States,

2000

by William S. Pearson, Ph.D., M.H.A., and Anita R. Bercovitz, Ph.D.,

M.P.H., Division of Health Care Statistics

Introduction

I

n 2004, President George W. Bush

signed Executive Order 13335,

which stated that within 10 years,

most Americans should be covered by

an interoperable (ability of health

information systems to work together

across organizational boundaries) health

record. This executive order created the

position of National Health Information

Technology Coordinator within the

Office of the Secretary of Health and

Human Services, with the charge of

developing a strategic plan that would

‘‘guide the nationwide implementation

of interoperable health information

technology in both the public and

private health care sectors that will

reduce medical errors, improve quality,

and produce greater value for health

care expenditures’’ (1).

Executive Order 13335 arrived on

the heels of two reports published by

the Institute of Medicine (IOM)

discussing patient safety concerns in

the U.S. health care system and how

information technology (IT) could help

increase levels of safety. The first

report, referred to as ‘‘Crossing the

Quality Chasm’’ (2), described how

the use of information technology

could ameliorate many of the quality

problems currently facing the U.S.

health care system. The second IOM

report, ‘‘Key Capabilities of an

Electronic Health Record’’ (3), further

outlined several key capabilities of an

electronic health record system that

would be necessary to address many

of the quality issues found in health

care. These key capabilities include

the ability to collect health

information and data, results

management, order entry and

management, decision support,

electronic communication and support,

patient support, administration support,

and population health reporting.

In 2000, it was estimated that

nearly 1.5 million patients were

receiving home health or hospice care in

the United States (4). The nature of care

provided in the home and to hospice

patients is different from many other

types of health care provided in other

settings. From the perspective of the

provider, patients are not centralized and

service coordination among different

providers may require a level of

planning that is not usually seen in other

care settings. Therefore, the capability to

communicate across health disciplines

and numerous health care providers

offered by a computerized medical

record (CMR) is particularly important

in the home health and hospice care

setting to reduce errors and increase

quality and efficiency.

This report presents the first

nationally representative data that

examines the extent of CMR use in the

home health and hospice care industry.

It summarizes the use of CMRs in the

home health and hospice industry in

2000 and identifies several agency

characteristics that are associated with

the use and adoption of information

technology in the form of a CMR.

Page 1
Page 2 [ Series 13, No. 160

Highlights

+ Approximately one-third of

agencies providing home health or

hospice services reported using a

CMR in 2000. Of those that were

not currently using CMRs, nearly

one-quarter stated that they had

plans to do so within the next

year.

+ CMR use varied by whether an

agency provided both home health

and hospice services or only one

type of service. Approximately

two-fifths (40.3%) of mixed-type

agencies, 32.1% of home health care

agencies, and 18.6% of hospice

agencies reported using a CMR in

2000.

+ In addition to differences in CMR

use among types of agencies, the

number of current active patients

served by the agency and agency

provision of high technology

services, such as respiratory,

intravenous, or enterostomal therapy,

were also significantly associated

with use of CMRs. Although 23.0%

of agencies with 50 or fewer

patients reported use of a CMR, the

proportion almost doubled (to

44.8%) among agencies with more

than 100 patients. Just over

30 percent (30.7%) of agencies with

50–100 patients reported use of a

CMR. Slightly over one-third

(34.8%) of agencies that provided

high technology services reported

using a CMR compared with

one-fifth (20.8%) of agencies that

did not provide high technology

services. Other agency

characteristics, including census

region, metropolitan statistical area

(MSA) location, ownership, and

agency affiliations, were not

associated with use of CMRs.

+ Among agencies providing home

health services (excluding hospice

only), the number of current active

patients served by the agency and

those providing high technology

services were the only significant

characteristics associated with CMR

use.

Methods

Data used for this report were

taken from the agency

component of the 2000 National

Home and Hospice Care Survey. In

2000, the sampling frame for this survey

consisted of 15,451 agencies. From this

sampling frame, 1,800 agencies were

selected for the survey, and 1,425 of

those agencies were identified as

currently providing care to patients at

the time of the survey and in scope

(eligible) for participation. This sample

of 1,425 agencies represents 11,400

agencies across the United States in

2000. For further information on the

sample selection and survey design, see

the survey methodology for the 2000

National Home Health and Hospice

Care Survey, which is available from:

http://www.cdc.gov/nchs/nhhcs.htm (5).

This report describes agency use of

CMRs. Two questions—1) ‘‘Are the

medical records of this agency

computerized?’’ and 2) ‘‘Does this

agency plan to computerize its records

within the next year?’’—were used in

this analysis. The first question was

asked of all 1,425 agencies. The second

question was asked of all facilities that

did not provide an affirmative response

to the first question. However, due to

small numbers of agencies responding

affirmatively to the second question, it

was not possible to examine the

responses to this question by various

agency characteristics. Therefore, only

the overall results for the response to

the second question are provided.

The use of a CMR was analyzed by

characteristics that may have an impact

on the delivery of care and might affect

the use of a CMR. The first

characteristic was agency type. Agencies

were classified as home health providers

only; hospice care providers only; or a

provider of both types of care, which

was termed ‘‘mixed.’’

Other agency characteristics

describing organizational structure and

operations included ownership status;

affiliation with a hospital, a group of

agencies, or a chain; size of the agency

based on patient load; total number of

services offered; specialty services

offered; and geographic location of the

agency. Estimates of CMR use were

made for each of these characteristics.

Ownership status and organizational

control was characterized as proprietary,

nonprofit, or government ownership.

Agencies were also identified as

whether they were operated by a

hospital and whether they were operated

by a larger group or belonged to a chain

of agencies.

Size of the agency was measured by

patient load and number of services

provided. The number of patients

currently being cared for by the agency

was categorized into three levels: 0–50

patients, 51–100 patients, and 101–500

patients. The total number of services

provided by the agency was also

categorized into three levels: 1–10

services, 11–20 services, and 21 or more

services.

The use of high technology services

by the agency was defined as providing

any of the following: respiratory

therapy, intraveneous therapy,

enterostomal therapy, and an affirmative

response to a question in the survey

regarding ‘‘other high technology

services.’’ The use of high technology

services was considered as a predictor

of CMR use for two reasons. First, these

types of services require care from

specialty-trained providers and therapists

and coordination of this level of care

could possibly be enhanced through

CMR management. Second, use of high

technology services could potentially be

an indicator of an agency’s willingness

to adopt newer technology.

Agency location was defined by

geographic location. This included

Northeast, Midwest, South, and West.

Metropolitan statistical area (MSA)

status was defined as metropolitan or

nonmetropolitan.

The relationship between use of a

CMR and agency characteristics was

also examined for agencies providing

home health services and excluded

hospice only providers. Agencies

providing hospice care only were

excluded for two reasons. The total

number of agencies providing hospice

care only was small, and further
Series 13, No. 160 [ Page 3

stratification of these agencies would

have provided unstable estimates. Also,

hospice care only providers could

potentially operate in a different

environment from agencies that provide

home health services. Agencies

providing only hospice care may be

providing their services in an inpatient

setting, which keeps all patients on

service in a close, centralized setting

when compared with patients receiving

care in their homes. This operational

structure may affect the choice of an

agency to use an electronic medical

record and may dilute the results of the

analysis.

When limiting the analyses to

agencies providing home health services

and excluding hospice only providers,

estimates using the same independent

variables as defined previously would

not have produced robust results.

Therefore, two of the agency

characteristics were dichotomized.

Ownership status was categorized into

either ‘‘proprietary’’ or ‘‘nonprofit,

government, or other’’ and number of

services was categorized into either

‘‘1–10 services’’ or ‘‘11 or more

services.’’

Estimates are reported for each of

the agency types and agency

characteristics. Estimates are not

presented in NCHS reports unless a

reasonable assumption regarding the

probability distribution of the sampling

error is possible. Estimates whose

standard error represents less than

30 percent of the estimate, but whose

sample sizes are between 30 and 60

have a single asterisk (*) to indicate that

they should be considered with caution.

Estimates whose standard error

represents more than 30 percent of the

estimate and have a sample size of less

than 30 have a double asterisk (**) to

indicate that they do not meet the

reliability standard set by NCHS. A

more detailed description of the

reliability of the estimates can be found

in Appendix I. In one instance of this

analysis, an estimate had a sample size

of 29. This sample size is less than the

NCHS-required sample size of 30–59

and is indicated with a dagger (†).

The association between agency

characteristics and use of a CMR were

tested for significance using bivariate

statistical tests. Chi-square tests were

used to test for significant differences

among the different levels of the

independent variables and between the

outcome responses. Significance levels

were set at an α=.05. For these tests,

responses of blank, invalid, or unknown

were not included in the analyses. These

categories represented less than 5% of the

responses. All analyses were conducted

using SAS callable SUDAAN (6) so as to

take into account the complex sampling

design of the survey.

Results

Overall Use of CMRs

Approximately one-third (32%) of

all home health and hospice agencies in

the United States were using CMRs in

2000. Of those that were not currently

using CMRs, 22% stated that they had

plans to do so within the next year

(Figure 1).

Looking more specifically at agency

type, nearly one-third of home health

agencies (32.1%) reported using a CMR

in 2000 compared with nearly one-fifth

of all hospice agencies (18.6%) and just

over two-fifths of all mixed-type

agencies (40.3%) (Table 1).

Characteristics of All

Agencies

Agencies with larger patient

volume had a higher percentage using

a CMR (p<.05). Agencies reporting

the provision of high technology

services also had a higher percentage

reporting use of a CMR (p<.05)

(Table 2).

No significant differences were seen

when comparing agency use of a CMR

by ownership, affiliation with a hospital,

number of services provided by the

agency, or on the geographic location of

the agency (Table 2).

Characteristics of Home

Health Service Agencies

When limiting the analyses to only

those agencies that provided home

health services, two characteristics—the

number of patients being treated and the

offering of high technology services—

were significantly related to the

agency’s likelihood of using a CMR.

Agencies serving more than 100 patients

were significantly more likely to be

using a CMR than agencies treating

fewer patients (p<.05). A significant

difference between agencies providing

high technology services and those not

providing high technology services was

noted in the analysis (p<.05); the same

as in the previous analysis. However,

the estimate should be considered with

caution due to the small sample size of

agencies indicating that they did not

provide high technology services

(Table 3). This sample size is less than

the NCHS-required sample size of

30–59.

Not using 

CMR 

68% 

No plans 

to use 

CMR 

78% 

Plans 

to use 

CMR 

22% 

Using CMR 

32% 

NOTES: CMR is computerized medical records. Percentages are based on 11,400 agencies.


DATA SOURCE: CDC/NCHS, National Health Interview Surveys, 2001.


Figure 1. Percent distribution of home health and hospice agencies currently using, or

planning to use within the next year, computerized medical records: United States, 2001
Page 4 [ Series 13, No. 160

Summary and

Discussion

I

n this first nationally representative

study of CMR use in the home

health and hospice industry, three

important characteristics were identified

as being related to an agency’s use of a

CMR. First, agencies that provide home

health services only or mixed services

are more likely than hospice only

providers to report currently using a

CMR. Second, agencies providing high

technology services had a greater

proportion of CMR users than those

agencies not offering high technology

services. Third, agencies that provided

services to large numbers of patients

were more likely to be users of CMR

technology compared with agencies

providing services to fewer patients. No

other characteristics were related to use

of a CMR.

Two prominent factors contribute to

the idea that home health agencies

would be identified as prime adopters of

this technology. First, the nature of

home health care (providing services in

multiple locations) requires coordination

among providers and provider sites.

Home health agencies provide services

to clients who are medically complex,

who often transition between modes of

care, who are served by multiple

providers and provider types, and who

are often geographically separated from

each other and the clients (7,8). In

contrast, hospice agencies are less likely

to transition between modes of care and

many times provide care in a centralized

setting such as an inpatient hospice care

facility. Additionally, it was considered

that agencies with more patients, those

that offered more services, and those

that offered more high technology

services may have more resources

available to invest in a computerized

medical record system.

The second prominent factor

considered was that in 1999 the Centers

for Medicare and Medicaid Services

(CMS) required home health agencies to

electronically submit patient assessments

to retain Medicare certification. These

assessments are collected in the

Outcome and Assessment Information

Set (OASIS) (9). This requirement

provided a federally mandated impetus

for home health agencies to acquire the

necessary infrastructure to electronically

record and transmit medical information

on their patients.

Other factors exist that may

simultaneously have negative affects on

the adoption of this technology. In

general, costs of acquiring and

implementing a CMR may be one

reason for the low proportion of

agencies using CMRs. This study

examined use of CMRs in 2000, which

was 2 years after implementation of the

interim payment system and 1 year after

implementation of the prospective

payment system (PPS) for home health

agencies. The changes in payment

methodology decreased home health

agencies’ reimbursement (10) and may

also have decreased the discretionary

funds available for purchase and

implementation of CMRs.

Another factor that may affect the

adoption of CMRs in home health and

hospice agencies is the availability of

specialized products directed specifically

for home health care. An example of

this technology is referred to as point of

care (POC) technology, which automates

nurses’ notes during the provision of

care in the home environment (11).

However, even with this new technology

advancement, a survey of health care IT

vendors found that although threequarters of respondents had developed

Electronic Medical Record (EMR) or

Electronic Health Record (EHR)

products for physician offices or

ambulatory clinics, fewer than

one-third had developed products

targeted at home health care (12). In

2000 and in previous years, electronic

health record technologies may not

have been as well marketed to the

home health industry as they were to

physician offices and ambulatory

clinics.

There were several limitations to

this study. One limitation is that the

surveyed agencies stated whether they

currently used a computerized medical

record, but did not elaborate on the

specific uses or characteristics of the

CMR. In most cases, an electronic

health record is used in coordinating

care among the different health

modalities and recording the treatment

of the patient. More detailed questions

on the uses of the electronic medical

record are being developed for future

National Home and Hospice Care

(NHHCS) surveys. These new questions

take into account the functionality and

interconnectivity standards set by Health

Level 7 (HL-7) (13) and also the ‘‘Key

Capabilities’’ of an electronic medical

record identified by the IOM.

A second limitation of this study is

that the data collected is cross-sectional.

It is not possible to determine if current

agency characteristics are the same as

those that existed when the CMR was

implemented. It is only possible to

determine a cross-sectional relationship

between CMR use and agency

characteristics.

A third limitation of this study was

the small sample size. Larger numbers

of the three types of agencies (home

health only, hospice only, and mixed)

would have made it possible to further

examine the relationship between

different types and modes of care

(including hospice only providers) and

CMR use.

It should to be noted in this study

that fundamental differences exist in the

way that home health and hospice care

are delivered, and these differences may

explain why home health agencies have

a higher percentage of CMR use when

compared with hospice only agencies.

There is relatively little literature

published on the use of an electronic

health record solely in the hospice care

setting. These differences should be

explored more fully in future research.

Therefore, this report, as well as future

home health and hospice care surveys,

will help to open the door on IT

research in long-term care and more

specifically in home health and hospice

care settings.
Series 13, No. 160 [ Page 5

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Page 6 [ Series 13, No. 160

Table 1. Weighted number and percent of agencies using a computerized medical record (with standard error), by agency type:

United States, 2000

Total number Number using Percent using

Agency type of agencies CMR1 CMR1

Home health agency ....................... 7,600 (300) 2,400 (200) 32.1 (2.4)

Hospice agency .......................... 1,300 (100) 200 (30) 18.6 (2.1)

Mixed agency ........................... 1,800 (200) 700 (100) 40.3 (4.6)

Total2

................................. 11,400 (300) 3,700 (200) 32.3 (1.9)

1CMR is computerized medical record.

2Includes unknown type.

Table 2. Percent distribution of agencies using a computerized medical record (with standard error), by selected agency characteristics:

United States, 2000

Percent Percent not

using using

Selected characteristic Total a CMR1 (n=3,700) a CMR1 (n=7,700)

Ownership

Proprietary ............................. 100.0 32.2 (3.0) 67.5 (3.0)

Nonprofit .............................. 100.0 31.7 (2.9) 68.2 (2.9)

Government ............................ 100.0 *33.2 (5.9) 66.8 (5.9)

Operated by hospital

Yes .................................. 100.0 35.7 (3.5) 64.3 (3.5)

No .................................. 100.0 31.0 (2.3) 68.8 (2.3)

Affiliated with group or chain

Yes .................................. 100.0 34.2 (2.5) 65.6 (2.5)

No, or affiliation unknown .................... 100.0 28.7 (3.1) 70.9 (3.1)

Number of patients2

0–50 ................................. 100.0 23.0 (2.7) 77.0 (2.7

51–100 ............................... 100.0 30.7 (3.8) 68.6 (3.8)

101–500............................... 100.0 44.8 (3.7) 54.9 (3.7)

Number of services provided

1–10 ................................. 100.0 32.4 (2.9) 67.2 (2.9)

11–20 ................................ 100.0 33.0 (2.6) 66.7 (2.6)

21 or more ............................. 100.0 *26.1 (7.5) 73.8 (7.5)

High technology services provided2

Yes .................................. 100.0 34.8 (2.1) 64.9 (2.1)

No .................................. 100.0 20.8 (4.4) 78.6 (4.4)

Location

Northeast .............................. 100.0 29.5 (4.3) 70.3 (4.3)

Midwest ............................... 100.0 30.6 (3.2) 69.1 (3.2)

South ................................ 100.0 33.2 (3.3) 66.5 (3.3)

West ................................. 100.0 35.0 (4.3) 64.0 (4.3)

MSA status3

MSA ................................. 100.0 33.8 (2.4) 65.8 (2.4)

Not MSA .............................. 100.0 29.3 (3.1) 70.3 (3.1)

* Figure does not meet standard of reliability or precision and should be considered with caution.

1CMR is computerized medical record.

2Chi-square test of association was significant at α ≤.05.

3MSA is metropolitan statistical area.

NOTE: Percentages may not add to 100 due to rounding.
Series 13, No. 160 [ Page 7

Table 3. Percent distribution of agencies delivering home health services that use a computerized medical record (with standard error), by

selected agency characteristics: United States, 2000

Percent Percent not

using CMR1 using CMR1

Selected characteristic Total (n=3,500) (n=6,100)

Ownership

Proprietary ............................. 100.0 35.1 (3.8) 64.8 (3.8)

Nonprofit, government, other .................. 100.0 33.2 (2.7) 66.8 (2.7)

Operated by hospital

Yes .................................. 100.0 31.8 (3.2) 68.1 (3.2)

No .................................. 100.0 35.3 (3.0) 64.6 (3.0)

Affiliated with group or chain

Yes .................................. 100.0 32.3 (3.3) 67.6 (3.3)

Not affiliated or affiliation unknown............... 100.0 35.2 (2.9) 64.7 (2.9)

Number of patients2

0–50 ................................. 100.0 24.5 (3.4) 75.4 (3.4)

51–100 ............................... 100.0 32.6 (4.3) 67.3 (4.3)

101–500............................... 100.0 45.5 (3.9) 54.4 (3.9)

Number of services provided

1–10 ................................. 100.0 32.4 (3.0) 67.5 (3.0)

11 or more ............................. 100.0 35.2 (3.1) 64.7 (3.1)

High technology services provided2

Yes .................................. 100.0 37.0 (2.4) 62.9 (2.4)

No .................................. 100.0 †19.1 (4.3) 80.8 (4.2)

Location

Northeast .............................. 100.0 *28.5 (4.7) 71.4 (4.7)

Midwest ............................... 100.0 31.9 (3.7) 68.0 (3.7)

South ................................ 100.0 34.9 (3.8) 65.0 (3.8)

West ................................. 100.0 *38.2 (5.1) 61.7 (5.1)

MSA status3

MSA ................................. 100.0 36.1 (2.8) 63.8 (2.8)

Not in MSA ............................. 100.0 29.6 (3.5) 70.3 (3.5)

† NCHS standard of reliability is normally based on a sample size of at least 30 cases. This estimate is based on 29 cases and should be considered with caution.

* Figure does not meet standard of reliability and should be considered with caution.

1CMR is computerized medical record.

2Chi-square test of association is significant at α<.05.

3MSA is metropolitan statistical area.

NOTES: Percentages may not add to 100 due to rounding. Percentages include home health and mixed type agencies. Agencies providng hospice services only were excluded.
Page 8 [ Series 13, No. 160

Appendix I

Technical Notes

Data in this report are from the

2000 National Home and Hospice Care

Survey (NHHCS), the sixth in a series

of surveys that was first conducted by

the National Center for Health Statistics

(NCHS) in 1992 (14). Other surveys

were conducted in 1993, 1994, 1996,

and 1998. NHHCS, a segment of the

long-term care component of the

National Health Care Survey (15),

collects information about agencies that

provide home health and hospice care

services, their current patients, and their

discharges.

Scope of the Survey

The sampling frame for NHHCS

consists of agencies classified as providing

home health or hospice care. These

agencies were originally identified through

the 1991 National Health Provider

Inventory (NHPI). NHPI is a

comprehensive census of nursing and

related care homes, residential care homes,

home health agencies, and hospices and

has been periodically conducted by

NCHS (16,17). For the 1992, 1994, and

1998 surveys, NHPI was updated using

the Agency Reporting System. This

system consisted primarily of lists of

directories of facilities from state agencies,

federal agencies, and national voluntary

organizations (17–19).

Starting with the 1998 NHHCS, the

universe of home health agencies and

hospices was obtained from various

national organizations and other sources.

The sampling frame for the 2000

NHHCS consisted of 15,451 agencies

and was obtained from two sources, the

SMG Home Healthcare Market

Database and the mailing list of

members of the National Hospice and

Palliative Care Organization (20,21).

The methodology used to create the

SMG file was similar to that used for

NHPI (obtaining lists of agencies

directly from states). The SMG file may

include agencies that provide both home

health and hospice care, but does not

include agencies that provide only

hospice care. The agencies within these

two sources were unduplicated prior to

the sample selection. The sample

consisted of 1,800 agencies selected

from this frame.

Sample Design

The sample design for the 2000

NHHCS was a two-stage probability

design (22). The first stage consisted of

the selection of a stratified sample of

agencies. Each agency was placed into 1

of 24 strata based on type of agency

(home health, hospice, and mixed),

metropolitan statistical area (MSA), and

region (Northeast, Midwest, South, and

West). MSA is defined by the U.S.

Office of Management and Budget on

the basis of the 1980 census. Within

these sampling strata, agencies were

arrayed by four types of ownership (for

profit, nonprofit, government, and

unknown), three types of certification

status (Medicare or Medicaid, not

certified, and unknown), state, MSA

code, county, ZIP code, and size

(number of current patients).

The second stage of sample

selection, sampling of six current

patients and six discharges within each

agency, was done using a sample

selection table to obtain systematic

probability samples of current patients

and discharges. The patients and

discharges were selected from lists

constructed for each agency at the time

of interview. Current patients were

defined as those patients who were on

the roll of the agency as of midnight on

the day immediately before the date of

the survey. Discharges referred to those

patients who were discharged from care

by the home health agency or hospice

during a designated month between

October 1999 and September 2000.

Discharges that occurred because of the

patient’s death were included.

Data Collection and Processing

Data collection for the 2000

NHHCS began with a letter sent to all

sampled agencies informing the

administrator of the authorizing

legislation, purpose, and content of the

survey. Each agency was then contacted

by an interviewer to discuss the survey

and to arrange an appointment with the

administrator. Three questionnaires and

two sampling lists were used to collect

the data. The Agency Questionnaire was

completed with the administrator or a

person designated by the administrator.

The interviewer then constructed the

Current Patient Sampling List and the

Discharged Patient Sampling List. These

lists were used to select the sample

patients and discharges. Sampling was

accomplished by using tables showing

sets of sample line numbers for each

possible count of current patients and

discharges in the agency. Up to six

current patients and six discharges were

selected.

After the samples had been

selected, the Current Patient

Questionnaires and the Discharged

Patient Questionnaires were completed

for each sampled person by interviewing

the staff member most familiar with the

care provided to the patient. The

respondent referred to patient medical

and other records as necessary. No

patient was interviewed directly. After

the data had been collected, they were

converted into machine-readable form.

Extensive editing was then conducted by

computer to ensure that all responses

were accurate, consistent, logical, and

complete. The medical information

recorded on the patient questionnaires

was coded according to the International

Classification of Diseases, 9th Revision,

Clinical Modification (23). Up to 12

diagnostic codes (a maximum of six at

admission and six at the time of survey

or discharge) and up to two procedure

codes were assigned for each sample

patient or discharge.

Estimation Procedure

Statistics presented in this report

were derived by a multistage estimation

procedure (24) that produces essentially

unbiased national estimates and has the

following three principal components:

(a) inflation by the reciprocals of the

probabilities of sample selection,

(b) adjustment for nonresponse, and

(c) ratio adjustment to fixed totals.

Inflation by the reciprocals of the

probabilities of sample selection—There

is a probability for each stage of

sampling: (a) the probability of selecting
Series 13, No. 160 [ Page 9

the agency, and (b) the probability for

selecting the patient or discharge within

each agency. For example, the

probability of selecting a discharge

within an agency is the number of

discharges selected divided by the total

number of discharges from the agency

within the designated month. The

overall probability of selection is the

product of the probabilities at each

stage. This component is the inverse of

the overall selection probability and is

the basic inflation weight.

Adjustment for nonresponse—NHHCS

data were adjusted for three types of

nonresponse. The first type occurred

when an in-scope (NHHCS eligible)

sample agency did not respond, the

second type occurred when an agency

did not complete the sampling lists used

to select the patient or discharge

samples, and the third type occurred

when the agency did not complete the

questionnaire for a sample patient or

discharge. The nonresponse adjustment

brings estimates based only on the

responding cases up to the level that

would have been achieved if all eligible

agencies had responded.

Ratio adjustment to fixed totals—

Adjustments were made within each of

four groups defined by region to adjust

for over- or under-sampling of agencies

reported in the sampling frame. This

adjustment is a multiplicative factor

whose numerator was the number of

agencies in the sampling frame within

each region and whose denominator was

the estimated number of agencies for

that same group.

Reliability of Estimates

Because the statistics presented in

this report are based on a sample, they

differ somewhat from values that would

have been obtained if a complete census

had been taken using the same

schedules, instructions, and procedures.

As in any sample survey, the results are

subject to both sampling and

nonsampling errors. Whenever possible,

the latter types of errors are kept to a

minimum by methods built into the

survey procedures. Because survey

results are subject to both sampling and

nonsampling errors, the total error is

larger than errors from sampling This is indicated with a double

variability alone. asterisk (**).

The standard error (SE) is primarily

a measure of the variability that occurs

by chance because a sample, rather than

the entire universe, is surveyed. The SE

also reflects part of the measurement

error, but it does not measure any

systematic biases in the data. The

chances are about 95 in 100 that an

estimate from the sample differs from

the value that would be obtained from a

complete census by less than twice the

SE. However, SEs typically

underestimate the true errors of the

statistics because they reflect only errors

resulting from sampling.

Standard errors in this report were

approximated using SUDAAN software.

SUDAAN computes SEs by a first-order

Taylor approximation of the deviation of

estimates from their expected values. A

description of the software and the

approach it uses has been published (6).

Presentation of Estimates

NCHS bases publication of

estimates for NHHCS on the relative

standard error (RSE) of the estimate and

the number of sample records on which

the estimate is based (referred to as the

sample size). RSE is another measure of

the variability and is calculated by

dividing the SE of an estimate by the

estimate itself. The result is then

converted into a percentage by

multiplying it by 100. Estimates are not

presented in NCHS reports unless a

reasonable assumption regarding the

probability distribution of the sampling

error is possible. Because of the

complex sample design of NHHCS, the

following guidelines are used:

+ If the sample size is 60 or more and

the RSE is less than 30 percent, the

estimate is reported and considered

reliable.

+ If the sample size is 30–59 or if the

sample is 60 or more and the RSE

is 30 percent or more, the estimate

is reported, but should not be

assumed reliable. This is indicated

with single asterisk (*) following the

figure in the table.

+ If the sample is less than 30, the

value of the estimate is not reported.
Page 10 [ Series 13, No. 160

Appendix II

Agency Questionnaire
Series 13, No. 160 [ Page 11
Page 12 [ Series 13, No. 160
Series 13, No. 160 [ Page 13
Page 14 [ Series 13, No. 160
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