Outcome And Assessment Information Set Data Research Articles

Assessing the accuracy of race-and-ethnicity data in the Outcome and Assessment Information Set.

Limitations in the quality of race-and-ethnicity information in Medicare's data systems constrain efforts to assess disparities in care among older Americans. Using demographic information from standardized patient assessments may be an efficient way to enhance the accuracy and completeness of race-and-ethnicity information in Medicare's data systems, but it is critical to first establish the accuracy of these data as they may be prone to inaccurate observer-reported or third-party-based information. This study evaluates the accuracy of patient-level race-and-ethnicity information included in the Outcome and Assessment Information Set (OASIS) submitted by home health agencies. We compared 2017-2022 OASIS-D race-and-ethnicity data to gold-standard self-reported information from the Medicare Consumer Assessment of Healthcare Providers and Systems® survey in a matched sample of 304,804 people with Medicare coverage. We also compared OASIS data to indirect estimates of race-and-ethnicity generated using the Medicare Bayesian Improved Surname and Geocoding (MBISG) 2.1.1 method and to existing Centers for Medicare & Medicaid Services (CMS) administrative records. Compared with existing CMS administrative data, OASIS data are far more accurate for Hispanic, Asian American and Native Hawaiian or other Pacific Islander, and White race-and-ethnicity; slightly less accurate for American Indian or Alaska Native race-and-ethnicity; and similarly accurate for Black race-and-ethnicity. However, MBISG 2.1.1 accuracy exceeds that of both OASIS and CMS administrative data for every racial-and-ethnic category. Patterns of inconsistent reporting of racial-and-ethnic information among people for whom there were multiple observations in the OASIS and Consumer Assessment of Healthcare Providers and Systems (CAHPS) datasets suggest that some of the inaccuracies in OASIS data may result from observation-based reporting that lessens correspondence with self-reported data. When health record data on race-and-ethnicity includes observer-reported information, it can be less accurate than both true self-report and a high-performing imputation approach. Efforts are needed to encourage collection of true self-reported data and explicit record-level data on the source of race-and-ethnicity information.

Functional Status and Mortality Among Older Adults with Multiple Myeloma

Introduction Multiple myeloma (MM) is disproportionately a disease of older adults, with a median age at diagnosis of 69. Prior single-center studies and therapeutic trials have demonstrated that aging-related functional impairments in activities of daily living (ADLs - e.g., bathing, toileting) are common among this population and predict treatment intolerance, healthcare utilization, and mortality. However, the prevalence and impact of functional impairments among broader, more generalizable populations of older adults with MM is less well understood. Methods We utilized cancer registry data from the Surveillance, Epidemiology, and End Results (SEER) program linked with Medicare enrollment and claims data from 2008-2019 and the Outcome and Assessment Information Set (OASIS) from 2008-2018 to construct a retrospective cohort of adults aged ≥66 diagnosed with MM between 2009 and 2017. OASIS data capture functional assessments for Medicare beneficiaries who are home health care recipients (HHRs). Individuals were deemed home health recipients if they had at least one OASIS assessment in the 12 months prior to MM diagnosis (inclusive of month of diagnosis). The primary exposures were (1) receipt of home health services prior to MM diagnosis and (2), degree of functional disability, a composite score derived from individual items related to ADLs contained in the OASIS data for HHRs and categorized by tertile as mild (composite score 0-11), moderate (12-17) or severe disability (18-40). The primary outcome was overall mortality within 5 years from diagnosis. Associations between primary exposures and outcomes were assessed via cumulative risk ratios (RRs) at 6, 12, and 36 months from diagnosis, with bootstrapped 95% confidence intervals. The association between receipt of any home health services and mortality was unadjusted; the association between degree of functional disability and mortality among those receiving home health services was adjusted for age, sex, race, and SEER region via inverse probability weighting. Results Among 41,635 beneficiaries with MM, 6,850 (16.4%) received home health services and had an OASIS assessment in the year prior to diagnosis. When compared to non-recipients, HHRs were older (38.6% in highest quartile vs 22.5%), more likely to be non-Hispanic Black (19.9%% vs 17.2%), and more likely to live in counties with greater rates of poverty (25.2% in highest quartile vs 21.7%). HHRs had similar rates of rural residence (10.5% vs 10.8%). Among HHRs, 79% required assistance with at least one ADL. Median number of activities with which HHRs required assistance was 3 (range 0-7). HHRs had higher all-cause mortality at all assessed time points compared to non-HHRs with MM (Figure 1); RRs were 1.91 (95% CI 1.83-1.99) at 6 months from diagnosis, 1.80 (1.74-1.86) at 12 months, and 1.50 at 36 months (1.47-1.53). Among HHRs, mortality was higher among those with severe functional disabilities compared to those with mild disability; RR for the severe versus mild disability groups was 1.38 (1.17-1.62) at 6 months, 1.29 (1.17-1.43) at 12 months, and 1.13 (1.08-1.19) at 36 months. In contrast, those with mild and moderate degrees of disability had similar survival (Figure 2), with non-significant differences in mortality at all assessed time points. Conclusions In this large nationwide study of older adults with MM, we describe the association between physical disability/activity dependence and 5-year mortality. These findings corroborate results of prior, smaller studies based on data from academic centers or therapeutic clinical trials. Our study is novel for its use of a large, diverse, and generalizable data source and the recent linkage with OASIS records. In this cohort, home health recipients had higher 5-year mortality compared to non-home health recipients. Additionally, mortality was most profoundly impacted among those with severe disabilities. In contrast, those with moderate degrees of disability had mortality rates that did not differ significantly from those individuals with mild disability. This moderate disability group, who had a median survival measured in years, may be at risk for undertreatment if their prognosis is underestimated. Future research will characterize the impact of physical disability on MM therapy receipt among this population. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Infection Hospitalization Trends Among US Home Healthcare Patients, 2013–2018

Background: Infections are a frequent cause of hospital (re)admissions for older adults receiving home health care (HHC) in the United States. However, previous investigators have likely underestimated the prevalence of infections leading to hospitalization due to limitations of identifying infections using Outcome and Assessment Information Set (OASIS), the standardized assessment tool mandated for all Medicare-certified HHC agencies. By linking OASIS data with inpatient data from the Medicare Provider Analysis and Review (MedPAR) file, we were able to better quantify infection hospitalization trends and subsequent mortality among HHC patients. Method: After stratification (by census region, ownership, and urban or rural location) and random sampling, our data set consisted of 2,258,113 Medicare beneficiaries who received HHC services between January 1, 2013, and December 31, 2018, from 1,481 Medicare-certified HHC agencies. The 60-day HHC episodes were identified in OASIS. Hospital transfers reported in OASIS were linked with corresponding MedPAR records. Our outcomes of interest were (1) hospitalization with infection present on admission (POA); (2) hospitalization with infection as the primary cause; and (3) 30-day mortality following hospitalization with infection as the primary cause. We identified bacterial (including suspected) infections based on International Classification of Disease, Ninth Revision (ICD-9) and ICD-10 codes in MedPAR. We classified infections by site: respiratory, urinary tract, skin/soft tissue, intravenous catheter-related, and all (including other or unspecified infection site). We also identified sepsis diagnoses. Result: From 2013 through 2018, the percentage of 60-day HHC episodes with 1 or more hospital transfers ranged from 15% to 16%. Approximately half of all HHC patients hospitalized had an infection POA. Over the 6 years studied, infection (any type) was the primary cause of hospitalization in more than a quarter of all transfers (25.86%–27.57%). The percentage of hospitalizations due to sepsis increased from 7.51% in 2013 to 11.49% in 2018, whereas the percentage of hospitalizations due to respiratory, urinary tract, or skin/soft-tissue infections decreased (p <0.001). Thirty-day mortality following a transfer due to infection ranged from 14.14% in 2013 to 14.98% in 2018; mortality rates were highest following transfers caused by sepsis (23.14%-26.51%) and respiratory infections (13.07%-14.27%). Conclusion: HHC is an important source of post-acute care for those aging in place. Our findings demonstrate that infections are a persistent problem in HHC and are associated with substantial 30-day mortality, particularly following hospitalizations caused by sepsis, emphasizing the importance of infection prevention in HHC. Effective policies to promote best practices for infection prevention and control in the home environment are needed to mitigate infection risk.Funding: NoDisclosures: None

Relationships of Severe Pain and Cognitive Impairment With Acute Care Use in Home Health Patients

Pain assessment is challenging in patients with cognitive impairment that can lead to inappropriate pain management and unfavorable health outcomes. Using a 10% random sample of Medicare home health (HH) patients ≥ 65 years old from the 2017 Outcome and Assessment Information Set (OASIS) national dataset (N=646,109), we tested the relationships of cognitive impairment and constant, severe pain that interfered with daily living activities with acute care utilization (i.e., hospitalization and emergency department [ED] admission without hospitalization). Patients who had constant, severe, interfering pain (32.57%, N=210,444) were younger, more likely to be female, white, Medicare-Medicaid dually eligible, living alone, and having functional limitations and depressive symptoms, but less likely to have moderate-to-severe cognitive impairment (25.0% versus 31.5%, p<0.001) than others. In multivariable logistic regression models adjusting for the above covariates, when compared with patients with neither cognitive impairment nor severe, constant, interfering pain, those with both conditions were 17% more likely to have hospitalization (Odds Ratio [OR]=1.17, p<0.001) and 13% more likely to have an ED admission without hospitalization (OR=1.13, p<0.001). This was the first study that examined co-occurring pain and cognitive impairment in HH recipients using national OASIS data. Findings suggest that: 1) older HH patients with moderate-to-severe cognitive impairment have lower rates of reported pain that suggests under-recognition; and 2) having severe, interfering pain among cognitively impaired patients significantly increased their risk of acute care utilization. Therefore, systematic protocols and guidelines should be in place to facilitate pain assessment for improved outcomes among HH patients with cognitive impairment.

Risk factors for infection in home health care: Analysis of national Outcome and Assessment Information Set data.

Patients in home health care (HHC), a rapidly growing healthcare sector, are at high risk for infections. This study aimed to identify risk factors for infections among HHC patients using the Outcome and Assessment Information Set (OASIS) data. We used a 5% random sample of the 2013 national OASIS data. Infections were identified if records indicated that patients were hospitalized or received emergency care for one of three types of infections (respiratory, wound site, and urinary tract infection). Multivariate logistic regression models were used to identify risk factors for each individual infection type. The final analysis included 128,163 patients from 8,255 HHC agencies nationwide. Approximately 3.2% of the patients developed infections during their HHC stay that led to hospitalization or emergency care treatment. We found that associations between demographics and infection risk are specific to the type of infection. In general, a history of multiple hospitalizations in past 6 months, comorbidity, having a severe condition at HHC admission, and impaired physical functioning increased HHC patients' risk of infections. We also identified that HHC patients with caregivers who needed training in providing medical procedure or treatment are at higher risk for wound-site infections. Our findings suggest that patients with underlying medical conditions and limited physical function status are more likely to develop infection. The caregiver's lack of training in providing needed care at home also places HHC patients at high risk for infection. Education for patients and caregivers should be tailored based on their health literacy level to ensure complete understanding.

Early Post-Intensive Care Syndrome among Older Adult Sepsis Survivors Receiving Home Care.

New or worsened disabilities in functional, cognitive, or mental health following an intensive care unit (ICU) stay are referred to as post-intensive care syndrome (PICS). PICS has not been described in older adults receiving home care. Our aim was to examine the relationship between length of ICU stay and PICS among older adults receiving home care. We expected that patients in the ICU for 3 days or longer would demonstrate significantly more disability in all three domains on follow-up than those not in the ICU. A secondary aim was to identify patient characteristics increasing the odds of disability. Retrospective cohort study. Hospitalization for sepsis in the United States. A total of 21 520 Medicare patients receiving home care and reassessed a median of 1 day (interquartile range 1-2 d) after hospital discharge. PICS was defined as a decline or worsening in one or more of 16 indicators tested before and after hospitalization using OASIS (Home Health Outcome and Assessment Information Set) and Medicare claims data. The sample was predominantly female and white. All had sepsis, and most (81.8%) had severe sepsis. In adjusted models, an ICU stay of 3 days or longer, compared with no ICU stay, increased the odds of physical disability. Overall, the declines were modest and found in specific activities of daily living (16% for feeding and lower body dressing to 26% for oral medicine management). No changes were identified in cognition or mental health. Significant determinants of new or worsened physical disabilities were sepsis severity, older age, depression, frailty, and dementia. Older adults receiving home care who develop sepsis and are in an ICU for 3 days or longer are likely to develop new or worsened physical disabilities. Whether these disabilities remain after the early postdischarge phase requires further study. J Am Geriatr Soc 67:520-526, 2019.

Clustering of elderly patient subgroups to identify medication-related readmission risks

IntroductionHigh Risk Medication Regimen (HRMR) scores are weakly predictive of hospital readmissions for elderly home health care patients. HRMR is composed of three elements related to drug risks: polypharmacy (number of medications); Potentially Inappropriate Medications (PIM) known to be harmful to the elderly; and the Medication Regimen Complexity Index (MRCI) that weighs drugs by the complexity of their dosing and instructions. In this paper, we hypothesized that HRMR scores are more predictive for demographic subgroups of elderly patients. The study used Outcome and Assessment Information Set (OASIS) variables to identify subgroups of patients for whom the HRMR measures appeared more predictive for hospital readmissions. MethodsOASIS and medication data were reused from a study of 911 patients (355 males, 556 females; mean age 78.9) from 15 Medicare-certified home health care agencies that established the relationship between HRMR and hospital readmissions. Hierarchical agglomerative clustering using the Jaccard distance measure and average-link method identified patient subgroups based on the OASIS data. Receiver operating curve (ROC) analyses evaluated the predictive strength of the HRMR variables for each subgroup. Additional False Discovery Rate (FDR) analyses assessed whether the clustered relationships were chance. ResultsClustering of OASIS data for 911 patients identified six subgroups: patients with Good Functional Status (n=382); Females with Moderate to Severe Pain (n=354); patients with poor prognosis needing functional status assistance (n=419); patients with Poor Functional Status (n=287); Males with Adult Children as Caregiver (n=198); adults living alone with spouses as primary caregiver (n=127). ROC results relating these subgroups to HRMR risks were strongest for Males with Adult Children as Caregivers (AUC: polypharmacy, 0.73; PIM, 0.64; MRCI, 0.77). The findings for this subgroup also met the FDR analysis threshold (<=0.20). ConclusionsA risk of medication-related readmissions in elderly men with adult children as caregivers is consistent with research showing problems in medication adherence when seniors are supported by informal caregivers. The results from clustering analysis present a hypothesis for research on HRMR and on the relationship between adult caregivers and their fathers.

Infection in home health care: Results from national Outcome and Assessment Information Set data

Patients in home health care (HHC), the fastest growing health care sector, are at risk for infection. The existing research on infection in HHC is often limited by small sample sizes, local scope of inquiry, and a lack of current data. There is no national study examining agency-level infection rates. This secondary data analysis used a 20% random sample of the 2010 national Outcome and Assessment Information Set (OASIS) data. An infection case was identified when the HHC patient was hospitalized or received emergency care for respiratory infection, urinary tract infection, intravenous catheter-related infection, wound infection, or deterioration. Proportions of infection cases out of the total number of patients were calculated for the whole sample and for each HHC agency. The final analysis included 199,462 patients from 8,255 HHC agencies. Approximately 3.5% of patients developed infections during their HHC stay, leading to emergency care treatment or hospitalization. Seventeen percent of unplanned hospitalizations among HHC patients were caused by infections. The agency-level infection rate ranged from 0%-34%, with an average of 3.5%. To our knowledge, this is the first study to examine the proportion of hospitalizations or emergency care treatment caused by infection in HHC and the agency-level infection rate at a national level by using OASIS data. These data demonstrate that infection is a serious problem in HHC, and infection rates varied between agencies. The variance in agency level rates may be caused by differences in infection control policies and practices. Better infection surveillance system in HHC is needed to benchmark quality of care.

Is OASIS Effective in Predicting Rehospitalization for Home Health Care Elderly Patients?

Using the Outcome and Assessment Information Set (OASIS), this study examined the feasibility of using OASIS items to identify direct and indirect factors contributing to rehospitalization among elderly patients receiving home health care. The outcomes revealed that being male, having a median level of cognitive impairment, a lower level of functional ability, and the absence of support, such as environmental support, psychosocial support, or facilitated medical care directly contributed to rehospitalization. While being older, obese, having a poorer clinical status, receiving ADL and/or IADL and less frequent informal care contributed to rehospitalization indirectly through decreased functional ability. Home health care providers may take full advantage of OASIS data, assessing both the direct and indirect factors leading to rehospitalization to identify patients at risk and intervene when needed.

Outcome and Assessment Information Set Data That Predict Pressure Ulcer Development in Older Adult Home Health Patients

To identify risk factors for pressure ulcer (PrU) development in older adult home health patients from admission Outcome and Assessment Information Set (OASIS) data. Retrospective cohort study. A convenience sample of 5 home healthcare agencies from across the United States. The cohort sample included 5395 nonhospice patients 60 years or older who were admitted for intermittent skilled home healthcare between September 30, 2007, and January 30, 2009. OASIS data on age, sex, race/ethnicity, diagnoses, caregiving, mental health status, clinical status, and functional status relevant to PrU risk were extracted from the electronic medical record of eligible patients in participating agencies. Patient OASIS data were followed forward chronologically from admission to new PrU development or discharge. The 3323 females (61.6%) and 2072 males (38.4%) ranged from age 60 to 103 years (mean, 78.2 [SD, 8.6] years). The cumulative incidence of PrUs was 1.3% (n = 71 patients). Multiple logistic regression analyses revealed that bowel incontinence, needing assistance with grooming, dependence in ability to dress the upper body, dependence in ability to dress the lower body, dependence in toileting, inability to transfer, being chairfast or bedfast, and the presence of a PrU on admission were positively associated with new PrU development. Among patients who were PrU-free on admission, bowel incontinence and inability to transfer best predicted PrU development. Results suggest that OASIS data can be used to identify patients who are at risk for PrUs with potential for use nationwide.

Identifying Comorbidities in Home Health Care Patients: Does the Outcome and Assessment Information Set Have Incremental Value to Medicare Claims Data?

We compare the proportion of patients presenting with comorbid conditions among fee-for-service Medicare beneficiaries with heart failure obtained by using (a) home health care claims data, (b) data from the Medicare Provider Analysis and Review (MedPAR), and (c) the Outcome and Assessment Information Set (OASIS), using a unique database developed by linking the records of Medicare administrative data and the OASIS. Data from the MedPAR yielded a higher proportion of patients with comorbid conditions compared to the OASIS or home health care claims data (77%, 51%, and 51%, respectively), leading us to conclude that non-home health care claims data must be used for risk adjustment in studies involving home health care patients.

Initial home health outcomes under prospective payment.

To assess initial changes in home health patient outcomes under Medicare's home health Prospective Payment System (PPS), implemented by the Centers for Medicare and Medicaid Services (CMS) in October 2000. Pre-PPS and early PPS data were obtained from CMS Outcome and Assessment Information Set (OASIS) and Medicare claims files. Regression analysis was applied to national random samples (n=164,810) to estimate pre-PPS/PPS outcome and visit-per-episode changes. Outcome episodes were constructed from OASIS data and linked with Medicare claims data on visits. Outcome changes (risk adjusted) were mixed and generally modest. Favorable changes included higher improvement rates under PPS for functioning and dyspnea, higher community discharge rates, and lower hospitalization and emergent care rates. Most stabilization (nonworsening) outcome rates also increased. However, improvement rates were lower under PPS for wounds, incontinence, and cognitive and emotional/behavioral outcomes. Total visits per episode (case-mix adjusted) declined 16.6 percent although therapy visits increased by 8.4 percent. The outcome and visit results suggest improved system efficiency under PPS (fewer visits, similar outcomes). However, declines in several improvement rates merit ongoing monitoring, as do subsequent (posthome health) hospitalization and emergent care use. Since only the early PPS period was examined, longer-term analyses are needed.

Cost Impact of Medicare OASIS Outcome Measurement for Rural Home Health Agencies

Many home health agencies (HHA) are in small towns located in rural areas. Due to volume restraints, a rural home health agency desiring to excel financially must endeavor to understand OASIS (the Outcome and Assessment Information Set). Rural HHAs must ensure that their OASIS assessments are completed thoroughly, consistently, and accurately. OASIS was developed over more than a decade by researchers at the University of Colorado Health Sciences Center (see http://www.uchsc.edu/), with funding for Medicare and Medicaid Services (CMS) and the Robert Wood Johnson Foundation. The CMS requires that OASIS data be reported and this data is used for two purposes: “ to monitor outcomes of home health agency services and (as of October 2000) as an indicator of patient severity and needs in determining payment amounts under Medicare’s home health prospective payment system” (Keepnews, Capitman, and Rosati, pg. 79).

Measuring Outcomes in Home Health Care: Beyond the OASIS Data Set

The dramatic changes in health care during the last decade encouraged nurses to measure the effectiveness of their practice. In addition, the shift to a Prospective Payment System in 2000 forced home health care agencies to become more cost efficient while demonstrating improved patient care outcomes. Tools to measure outcomes include the Outcome and Assessment Information Set (OASIS) and the Omaha System. As part of the federally mandated, outcome-based, quality monitoring process, home health agencies use the collected OASIS data to identify target areas of service or care that indicate a need for improvement and compare their data to other home care agencies. This article describes how a home health agency in Wisconsin successfully integrated OASIS and Omaha System data into its performance improvement program to measure patient outcomes using data about surgical wounds as an exemplar.

A Study of Reliability and Burden of Home Health Assessment Using OASIS

ABSTRACT The Outcome and Assessment Information Set (OASIS) is used for outcome reporting, quality improvement, and case mix adjustment of per-episode payment for home health care. The research described here addresses interrater reliability of OASIS items and compares clinician time required to complete patient assessment with and without OASIS. Interrater reliability for OASIS data items was estimated using independent assessments by two clinicians for a sample of 66 patients. Incremental assessment time due to OASIS was estimated using interview data from two agency-matched groups of clinical care providers-one group who used OASIS in the assessment and a second group whose assessment did not include OASIS items. Interrater reliability is excellent (kappa > .80) for many OASIS items and substantial (kappa > 0.60) for most items. The reported time required to complete an assessment with OASIS did not differ from the time required for a comparable assessment without OASIS. The results of this study are being used to guide developmental efforts to improve OASIS items. They can also be informative to home health care agencies when interpreting OASIS-based outcome and case mix reports.

Outcome-Based Quality Improvement in the Information Age

The outcomes movement in home health care is expanding rapidly, with strong support from both the industry and Medicare. The Federal government has proposed requiring all Medicare-certified agencies to collect data items from the Outcome and Assessment Information Set (OASIS) to form the basis for standardized riskadjusted outcome reporting as part of a systematic outcome-based quality improvement (OBQI) approach. In addition to contributing to improving patient outcomes, OASIS data items, when combined with other assessment information, utilization data, and cost information, can provide home health care agencies with a powerful integrated information set for internal management and strategic planning.

Outcome-based quality improvement in home health care: the OASIS indicators.

The outcomes movement in home health care is expanding rapidly, with strong support from both the industry and Medicare. The Federal government has proposed requiring all Medicare-certified agencies to collect data items from the Outcome and Assessment Information Set (OASIS) to form the basis for standardized risk-adjusted outcome reporting as part of a systematic outcome-based quality improvement (OBQI) approach. In addition to contributing to improving patient outcomes, OASIS data items, when combined with other assessment information, utilization data, and cost information, can provide home health care agencies with a powerful integrated information set for internal management and strategic planning.