Facility-level Analysis Research Articles

Facility-Level Analysis of PET Scanning for Staging Among US Veterans With Non-small Cell Lung Cancer

PET scanning has been shown in randomized trials to reduce the frequency of surgery without cure among patients with potentially resectable non-small cell lung cancer (NSCLC). We examined whether more frequent use of PET scanning at the facility level improves survival among patients with NSCLC in real-world practice. In this prospective cohort study of 622 US veterans with newly diagnosed NSCLC, we compared groups defined by the frequency of PET scan use measured at the facility level and categorized as low (<25%), medium (25%-60%), or high (>60%). The median age of the sample was 69 years. Ninety-eight percent were men, 36% were Hispanic or nonwhite, and 54% had moderate or severe comorbidities. At low-, medium-, and high-use facilities, PET scan was performed in 13%, 40%, and 72% of patients, respectively (P<.0001). Baseline characteristics were similar across groups, including clinical stage based on CT scanning. More frequent use of PET scanning was associated with more frequent invasive staging (P<.001) and nonsignificant improvements in downstaging (P=.13) and surgery without cure (P=.12). After a median of 352 days of follow-up, 22% of the sample was still alive, including 22% at low- and medium-use facilities and 20% at high-use facilities. After adjustment and compared with patients at low-use facilities, the hazard of death was greater for patients at high-use facilities (adjusted hazard ratio [HR], 1.35; 95% CI, 1.05-1.74) but not different for patients at medium-use facilities (adjusted HR, 1.14; 95% CI, 0.88-1.46). In this study of veterans with NSCLC, markedly greater use of PET scanning at the facility level was associated with more frequent use of invasive staging and possible improvements in downstaging and surgery without cure, but greater use of PET scanning was not associated with better survival.

More Frequent Hemoglobin Measurements and More Frequent Epoetin Alfa Titrations Are Both Associated with Increased Epoetin Alfa Dose but Not More Time in Target Hemoglobin Range,

Abstract 4194For the past 20 years, management of hemoglobin (Hb) level via erythropoiesis-stimulating agents (ESAs), such as epoetin alfa (EPO) has been the norm in the care of end-stage renal disease (ESRD) patients. Recently, questions about patient safety and new economic bundling rules have brought renewed focus on appropriate Hb targets and how they relate to the use of EPO. Important issues related to Hb control are the frequency of Hb measurements, Hb value, the frequency of changes in EPO dose (titrations), and total EPO dose. Current practice aims to achieve greater control of Hb by more frequent measurement and finer EPO dose titrations. No studies have definitively shown that levels of titration and measurement frequency lead to better clinical outcomes or more efficient use of EPO. One large retrospective analysis found increasing Hb measurements and EPO dose titration frequency decreased patient variability around the facility-level Hb mean (Khan et al, 2011). However, a second study found that frequent titrations have been shown to be the most important driver of Hb cycling—potentially dangerous large fluctuations in Hb levels (Fishbane and Berns, 2005). The issue remains controversial.We conducted a retrospective database analysis in order to quantify the frequency of Hb dose titrations and measurements, and to evaluate their relationship to ESA dose and the ability to keep patients within a Hb range of 10–12 g/dL. Data from prevalent (≥ 120 days), adult (>18 years old) hemodialysis patients dialyzing at DaVita dialysis clinics ≥ 3 times per week between January 1, 2009 and December 31, 2010 were included.For every session, patients’ stable dosing periods were defined as any series of at least 3 doses during which the dose did not change more than 10% from first dose in the series. Dose holds were defined as ≥ 3 consecutive sessions with 0 EPO dose. An EPO dose of 0 lasting <3 consecutive sessions was ignored when identifying stable periods and holds. Doses not categorized as part of a stable period or a dose hold were considered transition periods. A dose titration was defined as a difference of > 10% between any of the following: the mean dose of 2 consecutive stable periods; the mean dose of stable period and next/previous dose in transition period; and 2 consecutive doses within a transition period. Transitions involving a dose hold were counted as 1 titration if the patient then returned to a dose within 10% of the mean of the prior period; or 2 titrations otherwise. Similar rules were developed for the minority of patients who received EPO once or twice per week. Correlations among measures (titrations/patient-month and Hb measurements/patient-month with mean monthly EPO dose and time with Hb in range) were assessed using Pearson product-moment correlation and linear regression (adjusted for racial composition, percentage of dialysis vascular access types, percentage with comorbidities, and mean age, vintage, and BMI) at the physician and the facility levels. Time in range was defined as total patient time in range/total patient-time. Facility level analyses were weighted by facility load (minimum of 300 patient-months) and are reported here.Information from 81,464 patients at 1,336 facilities was assessed. The mean number of titrations was 13.6 ± 2.83 (mean ± SD) per patient per year and the mean number of Hb measurements was 36.3 ± 8.24 per patient per year. The mean percent of patient-time in range among these facilities was 57.1% ± 5.8%. At the facility level, after adjustment for case mix factors (mean age, vintage, and BMI at facility, access types, and racial composition) the annual number of dose titrations per patient and Hb measurements per patient were not associated with the percent of patient-months within a 10–12 g/dL Hb range (p=0.12 and p=0.47; respectively). An analysis of ESA utilization showed that an increase of 1 titration per patient at the facility level was associated with an extra 18,000 U (p<0.001) per patient.In this retrospective study of >80,000 US dialysis patients over 2 years, neither increased Hb measurements nor increased EPO titrations were associated with improving patient-time in Hb range. However, increased EPO titrations were associated with significantly increased EPO utilization. Although these associations do not demonstrate causality (or the direction of potential causality), they do underscore the need to assess titration practices. Disclosures:Bond:DaVita Clinical Research: Employment; Affymax Inc: Research presented in this study was paid for by Affymax. Rubin:DaVita Clinical Research: Employment; Affymax: The research presented in this abstract was paid for by Affymax. Wang:DaVita Clinical Research: Employment; Affymax: The research presented in this abstract was paid for by Affymax. Yang:Affymax: Employment.

153 Effect of Maintenance Iron Protocols on ESA Dosing and Anemia Outcomes

EFFECT OF MAINTENANCE IRON PROTOCOLS ON ESA DOSING AND ANEMIA OUTCOMES Mahesh Krishnan; Joe Weldon; Steve Wilson; Irina Goyhkman; David Van Wyck; DaVita Inc., Denver, CO, USA Although intravenous (IV) iron was initially for use as a bolus, over half of the hemodialysis population receives IV iron for maintenance dosing. We determined the association between various maintenance iron protocols and anemia management outcomes by constructing a facility level analysis for maintenance iron use. IV iron sucrose dosing patterns were assessed in facilities with ≥10 prevalent (≤90 days) patients in 01/10. Facilities were categorized to a dosing pattern if >40% of patients received the same dose [25 mg 1x/wk (n=234), 50 mg 1x/wk (n=180) or 100 mg 1x/wk (n=285)]. Medication and laboratory values were then summarized across all patients in those clinics in each category. Reported lab values lagged by one month to allow for the effect of iron dosing patterns from the previous month. The anemia management outcomes are listed by pattern (Table). Median ESA dose was significantly lower in facilities dosing 100 mg than 25 mg/wk (P = 0.002). Hb levels did not differ. Dosing Pattern/ wk Median ESA Dose (U/month) Mean Iron Dose (mg/month) TSAT (%) mean±SD Ferritin (ng/ml) mean±SD 25 mg reference reference 30.0 ± 13.0 531 ± 320 50 mg -1,100 +66 30.6 ± 13.4 606 ± 352 100 mg -2,200 +123 32.4 ± 15.1 728 ± 429 This retrospective analysis suggests that monthly ESA requirements to maintain target hemoglobin may be lower with larger doses of maintenance iron. More detailed analyses and prospective studies are indicated to explore this possibility.

Patient Satisfaction With Hospitalists: Facility-Level Analyses

Despite concerns and disagreements about the impact of hospitalist models on health care, hospitalists are becoming the dominant means of providing inpatient care, and models continue to diversify. Understanding their impact and the factors that influence their adoption is essential. This study examined hospitalists' impact on patient satisfaction, considering a host of characteristics. Cross-sectional data received in calendar year 2008, aggregated to the facility level, represent 1777 hospitals (41% of which employed hospitalists) and 2 648 275 patients. Press Ganey's psychometrically sound inpatient satisfaction survey consists of 38 items (10 sections) rated on a 5-point Likert-type scale. Findings suggest that facilities with hospitalists may have an advantage regarding satisfaction with nursing and personal issues (eg, privacy, emotional needs, response to complaints), both of which may be related to broader communication issues. Moreover, teaching (overall satisfaction) and large facilities (satisfaction with admissions, nursing, and tests/treatments) might especially benefit from the presence of hospitalists. Exploring how specific hospitalist functions influence patient satisfaction may reap rewards.

Hospital-level variability in incisional hernia repair technique affects patient outcomes

Mesh placement during ventral incisional hernia repair has been shown to result in superior outcomes; however, significant variation persists in the adoption of this technique. We performed a multi-institutional study to understand how variation in surgical technique influences outcomes. This study is a retrospective, facility-level analysis of incisional hernia repairs performed at 16 veteran's administration medical centers between 1997 and 2002. Operative notes and a postoperative course were physician-abstracted from the medical record. Hospital rates for the type of hernia repair, mesh placement, and recurrence were calculated. Spearman's correlation and generalized linear models were performed. A total of 1,612 incisional hernia repairs with a median follow-up of 66.2 months were included in the study. The mean rate of mesh implantation was 63.7% but ranged from 37.5% to 90%. The 5-year recurrence rate was 25.6% and ranged from 16.0% to 38.4%. The rate of mesh use for the incisional hernia repair at the hospital level was associated significantly with the hospital recurrence rate for all cases (R(2) = .27; P = .04) and elective cases (R(2) = .31; P = .02). For every 10% increase in the rate of mesh placement, a corresponding 3.1% decrease was noted in the recurrence rates (P = .001). The hospital rate of mesh use was not associated significantly with rates of complications or patient satisfaction. Hospitals that adopted a higher rate of mesh repair for incisional hernia repairs had lower recurrence rates. These data support that the efficacy of mesh repair previously proven in clinical trials is highly translatable to effective practice in the field. Continued studies on the attributable risk of complications to mesh placement are ongoing.

Implementing Two-lane Highway Simulation Modeling into CORSIM1

While urban areas and the corresponding traffic demand continue to grow, rural areas are experiencing significant growth as well. This growth is now resulting in congestion on facilities that previously did not have any. One area that is becoming a concern, particularly in Florida, is rural areas transitioning into a more developed area. Access to these areas is usually by twolane highways, but within these areas, there may be an occasional traffic signal, and possibly segments of multilane highway as well. Currently, no analysis tool exists for analyzing two-lane highway facilities with occasional intersections. The signal spacing and other general characteristics of these roadways do not fit with the analysis criteria for signalized arterials in the Highway Capacity Manual (HCM), and the two-lane highway analysis procedure does not account for interruptions to the flow, such as from signals. To pursue further investigation of the traffic operations within these areas and to assist with developing a facilitylevel analysis methodology, a simulation tool is required. However, the existing simulation tools cannot fully meet the research demands. The objective of this project was to develop a simulation tool that is capable of modeling the combination of two-lane highway segments and signalized intersections. The development approach used was to incorporate this modeling capability into CORSIM by making the necessary additions and modifications to the existing CORSIM software code base. The primary issues that had to be addressed to implement this modeling capability included: developing the model components that deal with passing maneuvers in an oncoming lane, developing the model components that deal with passing lanes, and developing a mechanism to link highway segments to signalized intersections. Preliminary testing showed that the developed two-lane highway modeling logic produced results that are reasonably consistent with expected traffic flow theory and field observations discussed in the literature.

Patterns in nursing home medication errors: disproportionality analysis as a novel method to identify quality improvement opportunities

To explore the use of disproportionality analysis of medication error data as a novel method to identify relationships that might not be obvious through traditional analyses. This approach can supplement descriptive data and target quality improvement efforts. Data came from the Medication Error Quality Initiative (MEQI) individual event reporting system. Participants were North Carolina nursing homes who submitted incident reports to the Web-based MEQI data repository during the 2006 and 2007 reporting years. Data from 206 nursing homes were summarized descriptively and then disproportionality analysis was applied. Associations between medication type and possible causes at the state level were explored. A single nursing home was selected to illustrate how the method might inform quality improvement at the facility level. Disproportionality analysis of drug errors in this home was compared with benchmarking. Statewide, 59 drug-cause pairs met the disproportionality signal and 11 occurred in 10 or more reports. Among these, warfarin was co-reported with communication errors; esomeprazole, risperidone, and nitrofurantoin were disproportionately associated with transcription error; and oxycodone and morphine were disproportionately reported with name confusion. Facility-level analyses illustrate how descriptive frequencies and disproportionality analysis are complementary, but also identify different safety targets. Exploratory analysis tools can help identify medication error types that occur at disproportionate rates. Candidate associations might be used to target patient safety work, although further evaluation is needed to determine the value of this information.

A Facility-Level Analysis of the Long-Term Consequences of Environmental Auditing Among Hazardous Waste Generators

Several rationales recently proposed to explain the willingness of firms to voluntarily conduct environmental audits suggest the potential for environmental audits to impact compliance outcomes in the long run. Using a unique facility-level dataset from Michigan, we examine the determinants of environmental auditing and the effects of environmental auditing on inspection frequency and long-term compliance with the U.S. Resource Conservation and Recovery Act (RCRA) among hazardous waste generators. Our empirical methodology accounts for the potential endogeneity of the audit outcome and censoring of the future compliance measure. We find that larger facilities and those subject to more stringent regulations are more likely to audit. We also find that facilities with poor compliance records are less likely to audit. However, we find no significant long-run impact of auditing on inspection frequency or RCRA compliance among these Michigan facilities.

Rosiglitazone is associated with mortality in chronic hemodialysis patients.

Recent studies have associated rosiglitazone, a thiazolidinedione drug, with adverse cardiovascular outcomes in the general population with diabetes. Using data from the Dialysis Outcomes and Practice Patterns Study in the United States, we examined cardiovascular hospitalization and mortality associated with prescription of rosiglitazone, compared with other oral hypoglycemic agents, among 2393 long-term hemodialysis patients who were followed for a median of 1.1 yr. We assessed mortality risk using Cox models in patient-level and dialysis facility-level analyses that used the facility proportion of patients on rosiglitazone as the predictor (instrumental variable approach) and adjusted the models for demographics, comorbid conditions, laboratory values, and achieved dialysis dosage. Compared with patients prescribed other oral hypoglycemic agents, patients prescribed rosiglitazone had significantly higher all-cause (hazard ratio [HR] 1.38; 95% confidence interval [CI] 1.05 to 1.82) and cardiovascular (HR 1.59; 95% CI 1.14 to 2.22) mortality, and their adjusted HR for hospitalization with myocardial infarction was 3.5-fold higher (P = 0.02). We did not observe similar associations in a secondary analysis evaluating pioglitazone. By the instrumental variable approach, facilities with more than the median adjusted percentage (6.2%) of patients who had diabetes and were prescribed rosiglitazone had significantly higher all-cause mortality (HR 1.36; 95% CI 1.15 to 1.62) and cardiovascular mortality (HR 1.42; 95% CI 1.07 to 1.88) than facilities with less than the median expected percentage prescribed rosiglitazone. Our practice-based findings suggest significant associations of rosiglitazone use with higher cardiovascular and all-cause mortality among hemodialysis patients with diabetes.

Operational Performance Assessment for Two-Lane Highway Facilities

Transportation professionals have indicated that a facility-based evaluation methodology for two-lane highways would be much more useful and practical to them than just the individual segment and point analysis methodologies. A facility level analysis will allow the various features (e.g., isolated intersections, continuous grades, passing lanes) that are typical to an extended length of two-lane highway to be addressed in a combined analysis with a single performance measure and level of service value resulting. Currently, no operational analysis methodology exists to address two-lane highways with different segment types at the facility level. The scope of analysis provided in the HCM 2000 for two-lane highways is limited to a single segment within the facility. This paper describes an effort to develop a methodology for the operational analysis of a two-lane highway that includes occasional isolated signalized intersections. The developed methodology provides a model for the basic structure of a facility level analysis that will be amenable to the incorporation of a variety of segment types.

Greater First-Year Survival on Hemodialysis in Facilities in Which Patients Are Provided Earlier and More Frequent Pre-nephrology Visits

The aim of this study was to evaluate the relation between pre-nephrology visit (PNV) and 1-yr patient survival after hemodialysis (HD) induction. Data were analyzed from 8500 incident HD patients (on HD <or=30 d) in the Dialysis Outcomes and Practice Patterns Study (DOPPS) phases I and II. A visit to a nephrologist at least 1 mo before starting HD was regarded as PNV. Cox regression was used to estimate the adjusted hazard ratio (AHR) for mortality in the first year of HD in both patient- and facility-level analyses. All models were adjusted for age, sex, race, socioeconomic factors, cause of ESRD, 14 comorbid conditions, hemoglobin, serum albumin, and serum creatinine; accounted for facility clustering effects; and were stratified by country. In patient-level analysis, PNV was associated with significantly lower risk for death (AHR 0.57; P < 0.0001). Facility-level analysis also showed a significant lower risk for death in facilities with greater prevalence of PNV in both continuous models (AHR 0.92 per 10% greater facility mean %PNV; P < 0.0004) and in categorical models (AHR 0.71 for facilities with >90% of patients receiving PNV [first quartile] compared with facilities with <71% of patients receiving PNV [fourth quartile]; P = 0.001). These results provide not only patient-level but also facility practice evidence that PNV is related to improved patient survival during the first year after initiation of HD, indicating the possible mortality benefits with more increased attention to PNV.

Consistent Aspirin Use Associated with Improved Arteriovenous Fistula Survival among Incident Hemodialysis Patients in the Dialysis Outcomes and Practice Patterns Study

The relationship between aspirin use and arteriovenous fistula (AVF) survival has been lacking. The aim of this study was to evaluate the association between AVF survival and aspirin use. Data on 2815 incident hemodialysis patients (on dialysis <or= 30 d) using an AVF at enrollment into the Dialysis Outcomes and Practice Patterns Study between 1996 and 2004 were analyzed. Cox regression was used to examine the association between aspirin use and the risk of final AVF failure, first AVF failure, and a gastrointestinal bleeding event. Aspirin use was determined at baseline and one year later. Patients using aspirin at baseline and one year later were considered consistent aspirin users. All models accounted for facility clustering effects and were adjusted for age, race, gender, body mass index, prior permanent access failure, prior placement of a catheter, 10 comorbid conditions, laboratory data, and other medications, and stratified by regions. Consistent aspirin use was significantly related to a lower risk of final AVF failure. Facility-level analysis, which may reduce confounding by indication, also showed a nearly significant trend of reduced risk of final AVF failure with greater prevalence of consistent aspirin use within dialysis facilities (P for trend = 0.07). The occurrence of a new gastrointestinal bleeding event during the study period was not associated with aspirin use. These results suggest that consistent aspirin use may be beneficial for AVF survival among incident hemodialysis patients.

Association of Timely Administration of Prophylactic Antibiotics for Major Surgical Procedures and Surgical Site Infection

Prophylactic antibiotic (PA) administration 1 to 2 hours before surgical incision (SIP-1) is a publicly reported process measure proposed for performance pay. We performed an analysis of patients undergoing major surgical operations to determine if SIP-1 was associated with surgical site infection (SSI) rates in Department of Veterans Affairs (VA) hospitals. Patients with External Peer Review Program Surgical Care Improvement Project (SCIP)-1 data with matched National Surgical Quality Improvement Program data were included in the study. Patient and facility level analyses comparing SCIP-1 and SSI were performed. We adjusted for clustering effects within hospitals, validated SSI risk score, and procedure type (percentage of colon, vascular, orthopaedic) using generalized estimating equations and linear modeling. The study population included 9,195 elective procedures (5,981 orthopaedic, 1,966 colon, and 1,248 vascular) performed in 95 VA hospitals. Timely PA occurred in 86.4% of patients. Untimely PA was associated with a rate of SSI of 5.8%, compared with 4.6% in the timely group (odds ratio = 1.29, 95% CI 0.99, 1.67) in bivariable unadjusted analysis. Patient level risk-adjusted multivariable generalized estimating equation modeling found the SSI risk score was predictive of SSI (p < 0.001); SIP-1 was not associated with SSI. Hospital level multivariable generalized linear modeling found procedure mix (p < 0.0001), but not SIP-1 rate or facility volume, to be associated with facility SSI rate. The study had 80% power to detect a 1.75% difference for patient level SSI rates. Timely PA did not markedly contribute to overall patient or facility SSI rates. These data are important for the ongoing discourse on how to measure and pay for quality of surgical care.

Geography Matters: Relationships among Urban Residential Segregation, Dialysis Facilities, and Patient Outcomes

End-stage renal disease disproportionately affects black Americans. However, the impact of residential segregation by race-a prominent feature of many U.S. cities--on outcomes of patients receiving dialysis and on facility performance has not been evaluated. To examine the relationship among racial composition of ZIP codes in metropolitan areas, outcomes of patients receiving dialysis, and characteristics of dialysis facilities. Retrospective cohort study of patients receiving dialysis and cross-sectional study of dialysis facilities. U.S. metropolitan ZIP codes with differing percentages of black residents. Black and non-Hispanic white patients who initiated long-term dialysis between 1 January 1995 and 31 December 2002 (n = 399,424) and dialysis facilities in operation in December 2004 (n = 3244). Mortality and time to transplantation among patients receiving dialysis, and performance of dialysis facilities on the basis of quality indicators (anemia management, dialysis adequacy, and facility-level mortality rates). Most black patients (50.3%) but few white patients (5%) lived in the 3% (n = 769) of ZIP codes in which most residents were black. In analyses adjusted for patient and ZIP code characteristics, mortality rates were higher among white patients but not among black patients living in areas with a higher percentage of black residents (adjusted hazard ratio for ZIP codes with > or =75% black residents vs. <10% black residents, 1.14 [95% CI, 1.07 to 1.21] for white patients and 1.02 [CI, 0.99 to 1.06] for black patients). Time to transplantation was longer among both black and white patients (adjusted hazard ratio for ZIP codes with > or =75% black residents vs. <10% black residents, 0.84 [CI, 0.78 to 0.92] and 0.63 [CI, 0.57 to 0.71] for black patients and white patients, respectively). Dialysis facilities located in areas with a higher percentage of black residents were more likely to have higher-than-expected mortality rates and were less likely to meet performance targets. Patient-level analyses were restricted to black and non-Hispanic white patients. Patient-level and facility-level analyses focused only on the percentage of black residents in each ZIP code. The racial composition of urban residential areas is associated with time to transplantation and dialysis facility performance on standard quality measures. Closer scrutiny of care provided to patients receiving dialysis who live in predominantly black residential areas and to dialysis facilities operating in these areas may be warranted.

The process management triangle: An empirical investigation of process trade-offs

Advancing theory and understanding of process management issues continues to be a central concern for operations management research and practice. While an insightful body of knowledge – based primarily on studies at the process-level – exists on the management of capacity and inventory, the dynamism characterizing most operating and competitive systems poses an ongoing challenge for managers having to mitigate the impact of variability across different levels of operating systems (e.g., production processes, facilities, and supply chains). This paper builds on a conceptual framework, derived from queuing theory and termed the “process management triangle”, to explore the extent to which fundamental trade-offs between capacity utilization, variability and inventory (CVI) generalize to complex operations and business systems. To do so, empirical analyses utilizing comparatively unique data for the study of these process management issues – and collected from two distinct, vastly different levels of analysis – are presented. First, a simulation-based facility-level analysis using teaching case study data is presented. Second, an industry-level analysis employing archival economic data spanning three multi-year periods is considered. Collectively, these empirical analyses provide exploratory support for the generalization and extension of analytical insights on CVI trade-offs to both complex operations and business systems, although with decreasing explanatory power. The implications of these studies for furthering process management theory and understanding are framed around additional research propositions intended to guide future investigation of CVI trade-offs.

Explaining state Medicaid nursing home reimbursement.

Medicaid nursing home reimbursement methods and per diem rates affect costs, quality, equity, and access. State rate-setting is a laboratory of policymaking, which can inform state and federal Medicaid reform initiatives. This paper explains state Medicaid nursing facility rates in 1979-1994. Findings suggest that prospective facility-specific methods constrained rates in some but not all periods, particularly when older cost-reports were employed in rate-setting. Analysis failed to show that prospective class rate-setting methods constrained rate increases. Findings suggest that the efficacy of reimbursement methodology to control rates depends upon wider health care policy trends and that future facility-level analyses should consider policy contexts as between states.

Hospice in nursing homes: a facility-level analysis of the distribution of hospice beneficiaries.

Since 1989, the Medicare hospice benefit has been available to terminally ill individuals residing in nursing homes. We first describe the evolution and nature of hospice care for nursing home residents. We then utilize recent On-line Survey and Certification of Automated Records data on a national sample of Medicare/Medicaid certified nursing homes, merged with hospice Provider of Service and Area Resource File information, to examine the distribution of hospice beneficiaries in nursing homes. Bivariate analyses provide descriptive comparisons of homes with 0%, 0.1-4.9%, and 5%+ residents on the hospice benefit. Multinomial logistic regression reveals the influence of organizational, market, and environmental factors on the proportion of beneficiaries in nursing homes. Results indicate that significant numbers of homes have hospice patients and that these institutions may have strong incentives to convert residents to the Medicare hospice benefit.