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Home Health Use Following a Cancer Diagnosis Among Patients Enrolled in Medicare Advantage and Traditional Medicare: Findings From the Newly Linked SEER-Medicare and Home Health OASIS Data

Home Health Use Following a Cancer Diagnosis Among Patients Enrolled in Medicare Advantage and... Abstract Background This article describes characteristics of patients receiving home health following an initial cancer diagnosis, comparing those enrolled in Medicare Advantage (MA) and Traditional Medicare (TM), using the newly linked 2010–2014 National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER)-Medicare and home health Outcome and Assessment Information Set (OASIS) data. Methods We identified SEER-Medicare beneficiaries with at least one OASIS assessment within 3 months of cancer diagnosis in 2010-2014, and summarized their demographic and clinical characteristics. Demographic and diagnostic data were obtained from the SEER-Medicare data, while further details about cognitive status, mood, function, and medical history were obtained from OASIS. We assessed differences between MA and TM beneficiaries using chi-square tests for independence, t-tests, and Kruskal-Wallis tests. Resutls We identified 104 023 patients who received home health within 3 months of cancer diagnosis: 81 587 enrolled in TM and 22 436 enrolled in MA. TM cancer patients had higher unadjusted rates of home health use than MA patients (16.3% vs 10.3%, P < .001). TM cancer patients receiving home health had more limitations in their cognitive function than their MA counterparts and longer lengths of service (mean = 42.2 days vs 39.4 days, P < .001; median = 27 vs 26 days, interquartile range = 42). Conclusion This study demonstrates the large number of cancer patients in the SEER-Medicare-OASIS data and describes characteristics for TM and MA patients. These newly linked data can be used to assess home health care among older patients with cancer. Home health care is an important part of our nation’s support system for the elderly, providing postacute and long-term care to approximately 3.5 million vulnerable Medicare beneficiaries (1). To be eligible for Medicare-reimbursed home health care, a beneficiary must need intermittent skilled care (<8 h/d) and be unable to leave home without considerable effort. Physicians must certify patients’ eligibility. Medicare patients with cancer can receive home health care in many stages of the cancer care continuum, ranging from services provided following initial cancer treatment to supportive care towards the end of life. A study using the linked National Cancer Institute’s (NCI) Surveillance, Epidemiology, and End Results (SEER)-Medicare claims data from the late 1990s found that 29% of Medicare cancer patients used home health following diagnosis, with 23% of Medicare cancer patients receiving home health services within 6 months of their cancer diagnosis (2). In contrast, only 7.8% of Medicare beneficiaries without cancer received home health services (2). In a more recent study using SEER-Medicare data, Medicare beneficiaries receiving surgery for stage III colorectal cancer had the highest cumulative incidence of home health care in the 100 days following surgery (19.4%) compared with cancer patients with stage I or II colorectal cancer (6.4%) and matched controls without cancer (2.8%) (3). Although these previous studies are informative in highlighting the role of home health in cancer care, they do not include information on home health care received among patients enrolled in Medicare’s managed care program, Medicare Advantage (MA) (4). In 2018, 34% of Medicare beneficiaries were enrolled in MA (5). The home health benefit varies greatly between Traditional Medicare (TM) and MA. In TM, home health is a covered benefit for homebound beneficiaries needing skilled care. There is no cost-sharing for home health, and before 2019, home health agencies received a prospective payment for a 60-day episode of care. In contrast to TM, MA plans are paid a capitated, risk-adjusted rate to cover Part A and B benefits for enrollees, including home health care. MA plans have flexibility to charge cost-sharing for home health, require prior authorization and reauthorization, conduct utilization review, and/or limit home health networks. MA has financial incentives to lower costs, which could result in either less home health care use among cancer patients (to limit home health spending) or greater use as an alternative to higher cost settings (eg, inpatient rehabilitation facilities, skilled nursing facilities). Previous research suggests MA enrollees use less home health care than their TM counterparts; however, this previous work has not focused on home health care for cancer patients. For example, Waxman et al. (6), used home health Outcome and Assessment Information Set (OASIS) assessment data, to model the probability of home health use, the duration of home health episodes, and clinical outcomes as a function of MA vs TM enrollment. After adjusting for demographic and clinical patient characteristics, the odds of receiving home health among TM enrollees were 1.83 times that of MA (95% confidence interval = 1.82 to 1.84) and home health duration was 34% longer for TM (95% confidence interval = 32% to 34%). However, outcomes differences were small in magnitude and inconsistent across measures. Li et al. observed that the use of home health care per 1000 beneficiary-years was 4712 days in MA and 7257 days in TM (absolute difference: 2545 days per 1000 beneficiary-years). Additional work also found that MA enrollees had less home health use (6.8% vs 9.4%) and for shorter durations (69.4 days vs 72.5 days) in 2016 than their TM counterparts (7). Given MA enrollment among Medicare beneficiaries is expected to increase (8), as is the number of older patients with cancer likely needing home health services (9), it is important to understand differences in the use of home care for cancer patients enrolled in TM and MA. In an effort to address gaps in our understanding of home health use for patients with cancer, the NCI has recently linked its SEER-Medicare files with the OASIS, a mandatory patient assessment instrument that is completed for all home health patients upon the start of home health care and at regular intervals thereafter. OASIS data are available for both TM and MA patients. Linkage of the SEER-Medicare data with the OASIS home health assessment data provides researchers with a rich data resource to assess the frequency of home health care use among Medicare beneficiaries with cancer enrolled in TM and MA, the characteristics of cancer patients receiving home health care, and their health outcomes. The objective of this article is to introduce the newly linked SEER-Medicare-OASIS data. We present the characteristics of Medicare beneficiaries with cancer, treated in the SEER registry areas, who received home health care within 3 months of diagnosis. For cancer patients enrolled in TM and MA, we describe differences in the rates of home health use, demographic characteristics, cognitive and physical function, and length of service separately. This information can be useful to understand the characteristics of TM and MA cancer patients who are receiving home health and sets the stage for future research examining access to home health and outcomes of cancer patients by Medicare benefit design. Methods Data Sources SEER-Medicare The assessment used the linked SEER-Medicare data. The SEER data (https://seer.cancer.gov) are obtained from population-based cancer registries that are funded by the NCI. The SEER registries include clinical information about all incident cancers occurring in patients living within defined geographic areas, representing over 30% of the US population (10). For each patient, the SEER data include demographic information including age, sex, and race; the number of primary incident cancers; month and year of diagnosis; site and stage of disease at diagnosis; type of surgery performed; and vital status. The Medicare data from the Centers for Medicare and Medicaid Services (CMS) include an enrollment file and unique Health Insurance Claim number for each Medicare beneficiary. Medicare claims are present for all inpatient hospitalizations, outpatient hospital services, physician services, durable medical equipment, skilled nursing, home care, and hospice services for beneficiaries with TM coverage. Prescription drug information is available for beneficiaries with TM or MA coverage who have enrolled in Medicare Part D. All Medicare claims include dates of service and codes for specific diagnoses, procedures, and medications. The SEER and Medicare data are linked biennially for 94% of patients over the age of 65 years at the time of cancer diagnosis. The version of SEER-Medicare data used in this article includes cancer cases diagnosed from 1973 to 2013 and Medicare claims through 2014. OASIS The Home Health OASIS is a standardized assessment of home health patients’ socio-demographic and environmental characteristics, health services utilization, physical and mental health, and physical and cognitive function. All Medicare or Medicaid-certified home health agencies in the United States (approximately 11 668 in 2018) are required to submit OASIS assessments for all patients age 18+ years receiving skilled home health services reimbursed by Medicaid or Medicare (including both MA and TM). These assessments are completed at the start of care, at the time of transfer to an inpatient facility (without discharge from the agency), at the resumption of care (after inpatient stay), at discharge or death, and for recertification of services at the end of the authorization period (60 days). OASIS version C (OASIS-C) was introduced in 2010 after field testing and examination of inter-rater reliability, validity, and usability. Linkage of SEER-Medicare Data to OASIS-C We used data from the OASIS-C for calendar years 2010 to 2014 linked to the SEER-Medicare data, which includes patients newly diagnosed with cancer in the SEER data from 2010 to 2013. The linkage was accomplished using a CMS file that cross-walks each cancer patient’s unique Health Insurance Claim number to their beneficiary identifier that is used to uniquely identify persons in the OASIS data. Of the 718 248 SEER-Medicare patients newly diagnosed with cancer between 2010 and 2013, 254 265 had an OASIS assessment at any point between 2010 and 2014. The NCI’s Institutional Review Board, CMS, and each of the SEER Registries approved linkage of SEER-Medicare and OASIS data. Analytic Samples and Analysis From the population of SEER-Medicare beneficiaries with at least one OASIS assessment over the period of 2010 to 2014, we identified those whose first OASIS assessment was within 3 months of the month of their cancer diagnosis. This time period was defined as the month of diagnosis and the 3 months after. This yielded 104 023 SEER-Medicare patients who newly received home health within this time period. Because most patients have multiple OASIS assessments over their home health episode, we included data from the first OASIS start-of-care assessment only. To address questions about differences in cancer patients who have TM vs MA coverage, we compared patient characteristics for all patients in the SEER-Medicare data. We also report on TM vs MA differences in select characteristics focusing only on those SEER-Medicare patients who were in the SEER-Medicare-OASIS data. Information obtained from the SEER-Medicare data included demographics, marital status, dual-eligibility for Medicaid, cancer site, date of diagnosis, and Hierarchical Conditions Classification (HCC) score. To gain further insight into home health users, we used information obtained from the OASIS assessment. We present patients’ cognitive status, mood, functional abilities, recent history of an inpatient episode, and length of home health service. Cognitive status was operationalized as the patient’s current (day of admission assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands. We also report if a patient exhibited any cognitive, behavioral, and psychiatric symptoms. We present the patient’s perceived anxiety and if they met the clinical criteria for depression using the Patient Health Questionnaire-2 (Sheeran). Functional impairment included measures of a patient’s need for assistance in activities of daily living (ie, grooming, dressing, bathing, toileting transfer, toileting hygiene, transferring, feeding, and ambulation/locomotion) or instrumental activities of daily living (ie, food preparation and use of the telephone). We also used the OASIS data to identify if the patient had been in a hospital or other institution in the 2 weeks before receiving home health care and the length of home health services. Length of service in home health was defined as the duration between the admission date and discharge date for each episode. For persons with concurrent episodes from distinct providers, we summed home health days across all home health providers. We summarized the characteristics of SEER-Medicare patients receiving home health services with standard descriptive measures including medians, means, SDs, frequencies, and proportions. Statistical significance of differences between MA and TM beneficiaries was evaluated using chi-square tests for independence, t tests, and Kruskal-Wallis tests, as appropriate. Results In Table 1, we compare the characteristics of all SEER-Medicare patients enrolled in MA compared with TM. The two groups of cancer patients were similar in sex, stage of cancer at diagnosis, and clinical complexity as measured by the HCC score. However, the two groups differed by geography and slightly in terms of age, with more TM patients belonging to both the youngest and oldest age groups. Notably, the two populations also differed by race and dual eligibility for Medicaid, with more racial and ethnic minorities enrolled in MA and more dually eligible in TM. Table 1. Characteristics of all SEER-Medicare patients and SEER-Medicare patients with home health use* within 3† months of cancer diagnosis, by Medicare benefit (2010–2013) . All SEER-Medicare patients . SEER-Medicare patients receiving home health care . Percent of SEER-Medicare patients receiving home health care‡ . . TM . MA . TM . MA . TM . MA . Sex No. (%) No. (%) No. (%) No. (%)  Male 254 672 (51) 109 832 (50) 35 849 (44) 9985 (45) 14% 9%  Female 245 329 (49) 108 415 (50) 45 738 (56) 12 451 (55) 19% 11% Race§  Non-Hispanic white 391 209 (78) 154 663 (71) 63 008 (77) 16 358 (73) 16% 11%  Non-Hispanic black 46 204 (9) 22 458 (10) 8798 (11) 2934 (13) 19% 13%  Hispanic 30 032 (6) 22 382 (10) 5441 (7) 1950 (9) 18% 9%  Asian or Pacific Islander 24 276 (5) 15 207 (7) 3928 (5) 1070 (5) 16% 7%  Other 8280 (2) 3837 (2) 412 (1) 124 (1) 5% 3% Age at diagnosis, y  <65 48 043 (10) 13 170 (6) 7178 (9) 1365 (6) 15% 10%  65–69 112 382 (22) 53 137 (24) 13 866 (17) 3938 (18) 12% 7%  70–74 105 040 (21) 50 266 (23) 15 157 (19) 4619 (21) 14% 9%  75–79 88 716 (18) 42 032 (19) 15 553 (19) 4652 (21) 18% 11%  80+ 145 820 (29) 59 642 (27) 29 833 (37) 7862 (35) 20% 13% Marital status  Married or partnered 212 029 (42) 84 974 (39) 35 980 (44) 10 574 (47) 17% 12%  Not married or not partnered 240 964 (48) 109.402 (50) 40 490 (50) 10 397 (46) 17% 10%  Unknown 47 008 (9) 23 871 (11) 5117 (6) 1465 (7) 11% 6% Dually eligible for Medicaid‖  Full 72 857 (15) 15 757 (7) 14 484 (18) 1839 (8) 20% 12%  Partial 21 577 (4) 9130 (4s) 4505 (6) 1549 (7) 21% 17% Registry  Connecticut 26 159 (5) 7887 (4) 6006 (7) 1203 (5) 23% 15%  Detroit 28 947 (6) 9673 (4) 5916 (7) 1502 (7) 20% 16%  Georgia (all 4)¶ 59 586 (12) 20 692 (9) 8300 (10) 2517 (11) 14% 12%  Greater California 95 300 (19) 62 973 (29) 14 147 (17) 5639 (25) 15% 9%  Hawaii 5262 (1) 5498 (3) 283 (0) 318 (1) 5% 6%  Iowa 26 949 (5) 4712 (2) 3218 (4) 577 (3) 12% 12%  Kentucky 41 369 (8) 10 264 (5) 6915 (8) 1496 (7) 17% 15%  Los Angeles 31 352 (6) 26 920 (12) 6705 (8) 1831 (8) 21% 7%  Louisiana 32 582 (7) 13 023 (6) 6110 (7) 1958 (9) 19% 15%  New Jersey 75 663 (15) 13 769 (6) 14 969 (18) 2105 (9) 20% 15%  New Mexico 10 867 (2) 4838 (2) 1535 (2) 522 (2) 14% 11%  San Francisco or San Jose 28 697 (6) 19 769 (9) 3865 (5) 1247 (6) 13% 6%  Seattle 27 640 (6) 12 468 (6) 2244 (3) 861 (4) 8% 7%  Utah 9628 (2) 5761 (3) 1374 (2) 660 (3) 14% 11% SEER summary  Stage at diagnosis   Missing 65 043 (13) 26 981 (12) 11 486 (14) 3210 (14) 18% 12%   In situ 41 188 (8) 17 769 (8) 2708 (3) 668 (3) 7% 4%   Local 185 977 (37) 85 056 (39) 23 186 (28) 6261 (28) 12% 7%   Regional 81 190 (16) 35 663 (16) 18 883 (23) 5269 (23) 23% 15%   Distant 98 995 (20) 42 147 (19) 22 308 (27) 6317 (28) 23% 15%   Unstaged 27 608 (6) 10 631 (5) 3016 (4) 711 (3) 11% 7%  HCC† score   Missing 233 (0) 50 (0) 13 (0) 1 (0) 6% 2%   <1 (good) 287 901 (58) 126 253 (58) 39 138 (48) 10 444 (47) 14% 8%   1-2 134 585 (27) 58 964 (27) 25 676 (31) 7054 (31) 19% 12%   >2 (poor) 77 282 (15) 32 980 (15) 16 760 (21) 4937 (22) 22% 15%  Year of SEER diagnosis   2010 128 468 (26) 52 209 (24) 21 630 (27) 5027 (22) 17% 10%   2011 126 835 (25) 53 602 (25) 21 014 (26) 5536 (25) 17% 10%   2012 124 248 (25) 54 579 (25) 20 629 (25) 6002 (27) 17% 11%   2013 120 450 (24) 57 857 (27) 18 314 (22) 5871 (26) 15% 10% . All SEER-Medicare patients . SEER-Medicare patients receiving home health care . Percent of SEER-Medicare patients receiving home health care‡ . . TM . MA . TM . MA . TM . MA . Sex No. (%) No. (%) No. (%) No. (%)  Male 254 672 (51) 109 832 (50) 35 849 (44) 9985 (45) 14% 9%  Female 245 329 (49) 108 415 (50) 45 738 (56) 12 451 (55) 19% 11% Race§  Non-Hispanic white 391 209 (78) 154 663 (71) 63 008 (77) 16 358 (73) 16% 11%  Non-Hispanic black 46 204 (9) 22 458 (10) 8798 (11) 2934 (13) 19% 13%  Hispanic 30 032 (6) 22 382 (10) 5441 (7) 1950 (9) 18% 9%  Asian or Pacific Islander 24 276 (5) 15 207 (7) 3928 (5) 1070 (5) 16% 7%  Other 8280 (2) 3837 (2) 412 (1) 124 (1) 5% 3% Age at diagnosis, y  <65 48 043 (10) 13 170 (6) 7178 (9) 1365 (6) 15% 10%  65–69 112 382 (22) 53 137 (24) 13 866 (17) 3938 (18) 12% 7%  70–74 105 040 (21) 50 266 (23) 15 157 (19) 4619 (21) 14% 9%  75–79 88 716 (18) 42 032 (19) 15 553 (19) 4652 (21) 18% 11%  80+ 145 820 (29) 59 642 (27) 29 833 (37) 7862 (35) 20% 13% Marital status  Married or partnered 212 029 (42) 84 974 (39) 35 980 (44) 10 574 (47) 17% 12%  Not married or not partnered 240 964 (48) 109.402 (50) 40 490 (50) 10 397 (46) 17% 10%  Unknown 47 008 (9) 23 871 (11) 5117 (6) 1465 (7) 11% 6% Dually eligible for Medicaid‖  Full 72 857 (15) 15 757 (7) 14 484 (18) 1839 (8) 20% 12%  Partial 21 577 (4) 9130 (4s) 4505 (6) 1549 (7) 21% 17% Registry  Connecticut 26 159 (5) 7887 (4) 6006 (7) 1203 (5) 23% 15%  Detroit 28 947 (6) 9673 (4) 5916 (7) 1502 (7) 20% 16%  Georgia (all 4)¶ 59 586 (12) 20 692 (9) 8300 (10) 2517 (11) 14% 12%  Greater California 95 300 (19) 62 973 (29) 14 147 (17) 5639 (25) 15% 9%  Hawaii 5262 (1) 5498 (3) 283 (0) 318 (1) 5% 6%  Iowa 26 949 (5) 4712 (2) 3218 (4) 577 (3) 12% 12%  Kentucky 41 369 (8) 10 264 (5) 6915 (8) 1496 (7) 17% 15%  Los Angeles 31 352 (6) 26 920 (12) 6705 (8) 1831 (8) 21% 7%  Louisiana 32 582 (7) 13 023 (6) 6110 (7) 1958 (9) 19% 15%  New Jersey 75 663 (15) 13 769 (6) 14 969 (18) 2105 (9) 20% 15%  New Mexico 10 867 (2) 4838 (2) 1535 (2) 522 (2) 14% 11%  San Francisco or San Jose 28 697 (6) 19 769 (9) 3865 (5) 1247 (6) 13% 6%  Seattle 27 640 (6) 12 468 (6) 2244 (3) 861 (4) 8% 7%  Utah 9628 (2) 5761 (3) 1374 (2) 660 (3) 14% 11% SEER summary  Stage at diagnosis   Missing 65 043 (13) 26 981 (12) 11 486 (14) 3210 (14) 18% 12%   In situ 41 188 (8) 17 769 (8) 2708 (3) 668 (3) 7% 4%   Local 185 977 (37) 85 056 (39) 23 186 (28) 6261 (28) 12% 7%   Regional 81 190 (16) 35 663 (16) 18 883 (23) 5269 (23) 23% 15%   Distant 98 995 (20) 42 147 (19) 22 308 (27) 6317 (28) 23% 15%   Unstaged 27 608 (6) 10 631 (5) 3016 (4) 711 (3) 11% 7%  HCC† score   Missing 233 (0) 50 (0) 13 (0) 1 (0) 6% 2%   <1 (good) 287 901 (58) 126 253 (58) 39 138 (48) 10 444 (47) 14% 8%   1-2 134 585 (27) 58 964 (27) 25 676 (31) 7054 (31) 19% 12%   >2 (poor) 77 282 (15) 32 980 (15) 16 760 (21) 4937 (22) 22% 15%  Year of SEER diagnosis   2010 128 468 (26) 52 209 (24) 21 630 (27) 5027 (22) 17% 10%   2011 126 835 (25) 53 602 (25) 21 014 (26) 5536 (25) 17% 10%   2012 124 248 (25) 54 579 (25) 20 629 (25) 6002 (27) 17% 11%   2013 120 450 (24) 57 857 (27) 18 314 (22) 5871 (26) 15% 10% * Home health use is defined as at least one OASIS assessment during the follow-up period. HCC = hierarchical conditions category; MA = Medicare Advantage; OASIS = Outcome and Assessment Information Set; SEER = Surveillance, Epidemiology, and End Results; TM = Traditional Medicare. † Three months following diagnosis includes the month of diagnosis plus an additional 3 months. ‡ Percent of SEER-Medicare patients receiving home health care is calculated as the row percent. For example, 23% of SEER-Medicare patients enrolled in TM and living in the Connecticut region received home health within 3 months of their diagnosis. § Race or ethnicity information comes from the SEER registry. ‖ Dually eligible during the month of cancer diagnosis. ¶ Georgia includes Atlanta, Greater Georgia, and Rural Georgia data. Open in new tab Table 1. Characteristics of all SEER-Medicare patients and SEER-Medicare patients with home health use* within 3† months of cancer diagnosis, by Medicare benefit (2010–2013) . All SEER-Medicare patients . SEER-Medicare patients receiving home health care . Percent of SEER-Medicare patients receiving home health care‡ . . TM . MA . TM . MA . TM . MA . Sex No. (%) No. (%) No. (%) No. (%)  Male 254 672 (51) 109 832 (50) 35 849 (44) 9985 (45) 14% 9%  Female 245 329 (49) 108 415 (50) 45 738 (56) 12 451 (55) 19% 11% Race§  Non-Hispanic white 391 209 (78) 154 663 (71) 63 008 (77) 16 358 (73) 16% 11%  Non-Hispanic black 46 204 (9) 22 458 (10) 8798 (11) 2934 (13) 19% 13%  Hispanic 30 032 (6) 22 382 (10) 5441 (7) 1950 (9) 18% 9%  Asian or Pacific Islander 24 276 (5) 15 207 (7) 3928 (5) 1070 (5) 16% 7%  Other 8280 (2) 3837 (2) 412 (1) 124 (1) 5% 3% Age at diagnosis, y  <65 48 043 (10) 13 170 (6) 7178 (9) 1365 (6) 15% 10%  65–69 112 382 (22) 53 137 (24) 13 866 (17) 3938 (18) 12% 7%  70–74 105 040 (21) 50 266 (23) 15 157 (19) 4619 (21) 14% 9%  75–79 88 716 (18) 42 032 (19) 15 553 (19) 4652 (21) 18% 11%  80+ 145 820 (29) 59 642 (27) 29 833 (37) 7862 (35) 20% 13% Marital status  Married or partnered 212 029 (42) 84 974 (39) 35 980 (44) 10 574 (47) 17% 12%  Not married or not partnered 240 964 (48) 109.402 (50) 40 490 (50) 10 397 (46) 17% 10%  Unknown 47 008 (9) 23 871 (11) 5117 (6) 1465 (7) 11% 6% Dually eligible for Medicaid‖  Full 72 857 (15) 15 757 (7) 14 484 (18) 1839 (8) 20% 12%  Partial 21 577 (4) 9130 (4s) 4505 (6) 1549 (7) 21% 17% Registry  Connecticut 26 159 (5) 7887 (4) 6006 (7) 1203 (5) 23% 15%  Detroit 28 947 (6) 9673 (4) 5916 (7) 1502 (7) 20% 16%  Georgia (all 4)¶ 59 586 (12) 20 692 (9) 8300 (10) 2517 (11) 14% 12%  Greater California 95 300 (19) 62 973 (29) 14 147 (17) 5639 (25) 15% 9%  Hawaii 5262 (1) 5498 (3) 283 (0) 318 (1) 5% 6%  Iowa 26 949 (5) 4712 (2) 3218 (4) 577 (3) 12% 12%  Kentucky 41 369 (8) 10 264 (5) 6915 (8) 1496 (7) 17% 15%  Los Angeles 31 352 (6) 26 920 (12) 6705 (8) 1831 (8) 21% 7%  Louisiana 32 582 (7) 13 023 (6) 6110 (7) 1958 (9) 19% 15%  New Jersey 75 663 (15) 13 769 (6) 14 969 (18) 2105 (9) 20% 15%  New Mexico 10 867 (2) 4838 (2) 1535 (2) 522 (2) 14% 11%  San Francisco or San Jose 28 697 (6) 19 769 (9) 3865 (5) 1247 (6) 13% 6%  Seattle 27 640 (6) 12 468 (6) 2244 (3) 861 (4) 8% 7%  Utah 9628 (2) 5761 (3) 1374 (2) 660 (3) 14% 11% SEER summary  Stage at diagnosis   Missing 65 043 (13) 26 981 (12) 11 486 (14) 3210 (14) 18% 12%   In situ 41 188 (8) 17 769 (8) 2708 (3) 668 (3) 7% 4%   Local 185 977 (37) 85 056 (39) 23 186 (28) 6261 (28) 12% 7%   Regional 81 190 (16) 35 663 (16) 18 883 (23) 5269 (23) 23% 15%   Distant 98 995 (20) 42 147 (19) 22 308 (27) 6317 (28) 23% 15%   Unstaged 27 608 (6) 10 631 (5) 3016 (4) 711 (3) 11% 7%  HCC† score   Missing 233 (0) 50 (0) 13 (0) 1 (0) 6% 2%   <1 (good) 287 901 (58) 126 253 (58) 39 138 (48) 10 444 (47) 14% 8%   1-2 134 585 (27) 58 964 (27) 25 676 (31) 7054 (31) 19% 12%   >2 (poor) 77 282 (15) 32 980 (15) 16 760 (21) 4937 (22) 22% 15%  Year of SEER diagnosis   2010 128 468 (26) 52 209 (24) 21 630 (27) 5027 (22) 17% 10%   2011 126 835 (25) 53 602 (25) 21 014 (26) 5536 (25) 17% 10%   2012 124 248 (25) 54 579 (25) 20 629 (25) 6002 (27) 17% 11%   2013 120 450 (24) 57 857 (27) 18 314 (22) 5871 (26) 15% 10% . All SEER-Medicare patients . SEER-Medicare patients receiving home health care . Percent of SEER-Medicare patients receiving home health care‡ . . TM . MA . TM . MA . TM . MA . Sex No. (%) No. (%) No. (%) No. (%)  Male 254 672 (51) 109 832 (50) 35 849 (44) 9985 (45) 14% 9%  Female 245 329 (49) 108 415 (50) 45 738 (56) 12 451 (55) 19% 11% Race§  Non-Hispanic white 391 209 (78) 154 663 (71) 63 008 (77) 16 358 (73) 16% 11%  Non-Hispanic black 46 204 (9) 22 458 (10) 8798 (11) 2934 (13) 19% 13%  Hispanic 30 032 (6) 22 382 (10) 5441 (7) 1950 (9) 18% 9%  Asian or Pacific Islander 24 276 (5) 15 207 (7) 3928 (5) 1070 (5) 16% 7%  Other 8280 (2) 3837 (2) 412 (1) 124 (1) 5% 3% Age at diagnosis, y  <65 48 043 (10) 13 170 (6) 7178 (9) 1365 (6) 15% 10%  65–69 112 382 (22) 53 137 (24) 13 866 (17) 3938 (18) 12% 7%  70–74 105 040 (21) 50 266 (23) 15 157 (19) 4619 (21) 14% 9%  75–79 88 716 (18) 42 032 (19) 15 553 (19) 4652 (21) 18% 11%  80+ 145 820 (29) 59 642 (27) 29 833 (37) 7862 (35) 20% 13% Marital status  Married or partnered 212 029 (42) 84 974 (39) 35 980 (44) 10 574 (47) 17% 12%  Not married or not partnered 240 964 (48) 109.402 (50) 40 490 (50) 10 397 (46) 17% 10%  Unknown 47 008 (9) 23 871 (11) 5117 (6) 1465 (7) 11% 6% Dually eligible for Medicaid‖  Full 72 857 (15) 15 757 (7) 14 484 (18) 1839 (8) 20% 12%  Partial 21 577 (4) 9130 (4s) 4505 (6) 1549 (7) 21% 17% Registry  Connecticut 26 159 (5) 7887 (4) 6006 (7) 1203 (5) 23% 15%  Detroit 28 947 (6) 9673 (4) 5916 (7) 1502 (7) 20% 16%  Georgia (all 4)¶ 59 586 (12) 20 692 (9) 8300 (10) 2517 (11) 14% 12%  Greater California 95 300 (19) 62 973 (29) 14 147 (17) 5639 (25) 15% 9%  Hawaii 5262 (1) 5498 (3) 283 (0) 318 (1) 5% 6%  Iowa 26 949 (5) 4712 (2) 3218 (4) 577 (3) 12% 12%  Kentucky 41 369 (8) 10 264 (5) 6915 (8) 1496 (7) 17% 15%  Los Angeles 31 352 (6) 26 920 (12) 6705 (8) 1831 (8) 21% 7%  Louisiana 32 582 (7) 13 023 (6) 6110 (7) 1958 (9) 19% 15%  New Jersey 75 663 (15) 13 769 (6) 14 969 (18) 2105 (9) 20% 15%  New Mexico 10 867 (2) 4838 (2) 1535 (2) 522 (2) 14% 11%  San Francisco or San Jose 28 697 (6) 19 769 (9) 3865 (5) 1247 (6) 13% 6%  Seattle 27 640 (6) 12 468 (6) 2244 (3) 861 (4) 8% 7%  Utah 9628 (2) 5761 (3) 1374 (2) 660 (3) 14% 11% SEER summary  Stage at diagnosis   Missing 65 043 (13) 26 981 (12) 11 486 (14) 3210 (14) 18% 12%   In situ 41 188 (8) 17 769 (8) 2708 (3) 668 (3) 7% 4%   Local 185 977 (37) 85 056 (39) 23 186 (28) 6261 (28) 12% 7%   Regional 81 190 (16) 35 663 (16) 18 883 (23) 5269 (23) 23% 15%   Distant 98 995 (20) 42 147 (19) 22 308 (27) 6317 (28) 23% 15%   Unstaged 27 608 (6) 10 631 (5) 3016 (4) 711 (3) 11% 7%  HCC† score   Missing 233 (0) 50 (0) 13 (0) 1 (0) 6% 2%   <1 (good) 287 901 (58) 126 253 (58) 39 138 (48) 10 444 (47) 14% 8%   1-2 134 585 (27) 58 964 (27) 25 676 (31) 7054 (31) 19% 12%   >2 (poor) 77 282 (15) 32 980 (15) 16 760 (21) 4937 (22) 22% 15%  Year of SEER diagnosis   2010 128 468 (26) 52 209 (24) 21 630 (27) 5027 (22) 17% 10%   2011 126 835 (25) 53 602 (25) 21 014 (26) 5536 (25) 17% 10%   2012 124 248 (25) 54 579 (25) 20 629 (25) 6002 (27) 17% 11%   2013 120 450 (24) 57 857 (27) 18 314 (22) 5871 (26) 15% 10% * Home health use is defined as at least one OASIS assessment during the follow-up period. HCC = hierarchical conditions category; MA = Medicare Advantage; OASIS = Outcome and Assessment Information Set; SEER = Surveillance, Epidemiology, and End Results; TM = Traditional Medicare. † Three months following diagnosis includes the month of diagnosis plus an additional 3 months. ‡ Percent of SEER-Medicare patients receiving home health care is calculated as the row percent. For example, 23% of SEER-Medicare patients enrolled in TM and living in the Connecticut region received home health within 3 months of their diagnosis. § Race or ethnicity information comes from the SEER registry. ‖ Dually eligible during the month of cancer diagnosis. ¶ Georgia includes Atlanta, Greater Georgia, and Rural Georgia data. Open in new tab Across all cancers, TM cancer patients had higher rates of home health use in the 3 months following a cancer diagnosis than MA patients with cancer (16.3% compared with 10.3%) (Table 1). Compared with MA patients, TM patients receiving home health were more likely to be white, younger than 65 years and older than 80 years old, not married or no partner, and dually eligible for Medicaid. Utilization differences between MA and TM varied by geographic location: the largest share of SEER-Medicare TM beneficiaries receiving home health were in New Jersey and the Greater California registries, whereas the largest share of MA beneficiaries were in the Greater California and Georgia registries. Patients in Hawaii and Seattle had the lowest rates of home health use regardless of their Medicare enrollment. Patients who had cancers with the highest incidence, including lung, breast, and colorectal, also constituted the largest group of patients using HH. However, patients with cancers that have a poor prognosis, such as ovarian and pancreatic, also frequently received home health care (Table 2). From the OASIS assessment, we observed that cancer patients enrolled in TM and receiving home health within 3 months of their cancer diagnosis were more likely to have limitations in their cognitive function as well as to suffer from memory deficits and impaired decision-making (Table 3) than their MA counterparts. Furthermore, they were more likely to require assistance in all their activities and instrumental activities of daily living. Regardless of enrollment status, more than 90% of cancer patients receiving home health within 3 months of their cancer diagnosis required assistance with bathing, over 85% needed assistance with ambulation/locomotion, and more than 80% needed assistance with dressing and preparing meals. TM cancer patients receiving home health during this time period were more likely to experience constant or daily, intermittent pain than those enrolled in MA (P = .001) and more likely to exhibit anxiety symptoms. There were no differences in depression between MA and TM. Table 2. Frequency of home health* use within 3† months of diagnosis among SEER‡-Medicare patients diagnosed with cancer, by cancer site and Medicare benefit (2010–2013) . SEER-Medicare patients diagnosed with cancer, No. . SEER-Medicare patients who used home health* in the 3 months following cancer diagnosis, No. . SEER cancer type . TM . MA . TM . MA . . No. . No. . No. (%) . No. (%) . Bladder 25 002 10 726 3668 (14.7) 1068 (10.0) Breast 63 145 30 458 8132 (12.9) 1926 (6.3) Colorectal 43 341 19 313 11 527 (26.6) 3193 (16.5) Kidney (RCC‡) 14 730 6186 2666 (18.1) 745 (12.0) Leukemias 12 565 5150 1738 (13.8) 460 (8.9) Lung 73 336 29 730 15 420 (21.0) 4211 (14.2) Multiple cancers§ 7495 2980 1716 (22.9) 461 (15.5) Non-Hodgkin’s lymphoma 19 190 8330 3145 (16.4) 910 (10.9) Other cancers§ 133 997 56 289 22 483 (16.8) 6469 (11.5) Ovarian 5747 2572 1577 (27.4) 451 (17.5) Pancreatic 15 981 6968 3640 (22.8) 973 (14.0) Prostate 66 237 30 946 3255 (4.9) 816 (2.6) Thyroid 5644 2255 370 (6.6) 116 (5.1) Uterine 13 591 6344 2250 (16.6) 637 (10.0) Total 500 001 218 247 81 587 (16.3) 22 436 (10.3) . SEER-Medicare patients diagnosed with cancer, No. . SEER-Medicare patients who used home health* in the 3 months following cancer diagnosis, No. . SEER cancer type . TM . MA . TM . MA . . No. . No. . No. (%) . No. (%) . Bladder 25 002 10 726 3668 (14.7) 1068 (10.0) Breast 63 145 30 458 8132 (12.9) 1926 (6.3) Colorectal 43 341 19 313 11 527 (26.6) 3193 (16.5) Kidney (RCC‡) 14 730 6186 2666 (18.1) 745 (12.0) Leukemias 12 565 5150 1738 (13.8) 460 (8.9) Lung 73 336 29 730 15 420 (21.0) 4211 (14.2) Multiple cancers§ 7495 2980 1716 (22.9) 461 (15.5) Non-Hodgkin’s lymphoma 19 190 8330 3145 (16.4) 910 (10.9) Other cancers§ 133 997 56 289 22 483 (16.8) 6469 (11.5) Ovarian 5747 2572 1577 (27.4) 451 (17.5) Pancreatic 15 981 6968 3640 (22.8) 973 (14.0) Prostate 66 237 30 946 3255 (4.9) 816 (2.6) Thyroid 5644 2255 370 (6.6) 116 (5.1) Uterine 13 591 6344 2250 (16.6) 637 (10.0) Total 500 001 218 247 81 587 (16.3) 22 436 (10.3) * Home health use is defined as at least one OASIS assessment during the follow-up period. MA = Medicare Advantage; OASIS = Outcome and Assessment Information Set; RCC = renal cell carcinoma; SEER = Surveillance, Epidemiology, and End Results; TM = Traditional Medicare. † Three months following diagnosis includes the month of diagnosis plus an additional 3 months. ‡ Renal cell carcinoma. § Multiple cancers refers to individuals who were diagnosed with more than one cancer. Other cancers include cancers of the anus, bone and joint, brain and other nervous system, cervix uteri, esophagus, larynx, liver, Hodgkin’s lymphoma, melanoma, myeloma, oral cavity and pharynx, small intestine, stomach, testis, and vulva. Open in new tab Table 2. Frequency of home health* use within 3† months of diagnosis among SEER‡-Medicare patients diagnosed with cancer, by cancer site and Medicare benefit (2010–2013) . SEER-Medicare patients diagnosed with cancer, No. . SEER-Medicare patients who used home health* in the 3 months following cancer diagnosis, No. . SEER cancer type . TM . MA . TM . MA . . No. . No. . No. (%) . No. (%) . Bladder 25 002 10 726 3668 (14.7) 1068 (10.0) Breast 63 145 30 458 8132 (12.9) 1926 (6.3) Colorectal 43 341 19 313 11 527 (26.6) 3193 (16.5) Kidney (RCC‡) 14 730 6186 2666 (18.1) 745 (12.0) Leukemias 12 565 5150 1738 (13.8) 460 (8.9) Lung 73 336 29 730 15 420 (21.0) 4211 (14.2) Multiple cancers§ 7495 2980 1716 (22.9) 461 (15.5) Non-Hodgkin’s lymphoma 19 190 8330 3145 (16.4) 910 (10.9) Other cancers§ 133 997 56 289 22 483 (16.8) 6469 (11.5) Ovarian 5747 2572 1577 (27.4) 451 (17.5) Pancreatic 15 981 6968 3640 (22.8) 973 (14.0) Prostate 66 237 30 946 3255 (4.9) 816 (2.6) Thyroid 5644 2255 370 (6.6) 116 (5.1) Uterine 13 591 6344 2250 (16.6) 637 (10.0) Total 500 001 218 247 81 587 (16.3) 22 436 (10.3) . SEER-Medicare patients diagnosed with cancer, No. . SEER-Medicare patients who used home health* in the 3 months following cancer diagnosis, No. . SEER cancer type . TM . MA . TM . MA . . No. . No. . No. (%) . No. (%) . Bladder 25 002 10 726 3668 (14.7) 1068 (10.0) Breast 63 145 30 458 8132 (12.9) 1926 (6.3) Colorectal 43 341 19 313 11 527 (26.6) 3193 (16.5) Kidney (RCC‡) 14 730 6186 2666 (18.1) 745 (12.0) Leukemias 12 565 5150 1738 (13.8) 460 (8.9) Lung 73 336 29 730 15 420 (21.0) 4211 (14.2) Multiple cancers§ 7495 2980 1716 (22.9) 461 (15.5) Non-Hodgkin’s lymphoma 19 190 8330 3145 (16.4) 910 (10.9) Other cancers§ 133 997 56 289 22 483 (16.8) 6469 (11.5) Ovarian 5747 2572 1577 (27.4) 451 (17.5) Pancreatic 15 981 6968 3640 (22.8) 973 (14.0) Prostate 66 237 30 946 3255 (4.9) 816 (2.6) Thyroid 5644 2255 370 (6.6) 116 (5.1) Uterine 13 591 6344 2250 (16.6) 637 (10.0) Total 500 001 218 247 81 587 (16.3) 22 436 (10.3) * Home health use is defined as at least one OASIS assessment during the follow-up period. MA = Medicare Advantage; OASIS = Outcome and Assessment Information Set; RCC = renal cell carcinoma; SEER = Surveillance, Epidemiology, and End Results; TM = Traditional Medicare. † Three months following diagnosis includes the month of diagnosis plus an additional 3 months. ‡ Renal cell carcinoma. § Multiple cancers refers to individuals who were diagnosed with more than one cancer. Other cancers include cancers of the anus, bone and joint, brain and other nervous system, cervix uteri, esophagus, larynx, liver, Hodgkin’s lymphoma, melanoma, myeloma, oral cavity and pharynx, small intestine, stomach, testis, and vulva. Open in new tab Table 3. Cognitive and physical function of SEER-Medicare patients with home health* use within 3 months† of cancer diagnosis, by Medicare benefit (2010–2013) . TM . MA . . . No. (%) . No. (%) . P‡ . Cognitive function <.0001  Alert or oriented, able to focus and shift attention, comprehends and recalls task directions independently 50 760 (62.22) 14 976 (66.75)  Requires some prompting or assistance 29 256 (35.86) 7029 (31.33)  Requires considerable assistance or totally dependent 1571 (1.93) 431 (1.92) Cognitive, behavioral, and psychiatric symptoms  Memory deficit 9287 (11.38) 2376 (10.59) .0009  Impaired decision-making 11 900 (14.59) 2701 (12.04) <.0001  Verbal disruption, aggression, inappropriate behavior, delusional 1168 (1.43) 286 (1.28) .0763  None of above behaviors demonstrated 64 586 (79.16) 18 402 (82.02) <.0001 Needs assistance in activities of daily living  Grooming 60 872 (74.61) 15 841 (70.61) <.0001  Dressing§ 69 800 (85.55) 18 380 (81.92) <.0001  Bathing 77 666 (95.19) 20 953 (93.39) <.0001  Toileting transfer 49 804 (61.04) 12 858 (57.31) <.0001  Toileting hygiene 55 461 (67.98) 14 123 (62.95) <.0001  Transferring 65 637 (80.45) 17 381 (77.47) <.0001  Feeding 46 474 (56.96) 12 249 (54.60) <.0001  Ambulation or locomotion 71 873 (88.09) 19 182 (85.50) <.0001 Needs assistance in instrumental activities of daily living  Food preparation 67 522 (82.76) 18 323 (81.67) .0001  Use of phone 23 852 (29.24) 6092 (27.15) <.0001 Pain  None 18 429 (22.59) 5579 (24.87) <.0001  Present but does not interfere with activity 8290 (10.16) 2575 (11.48)  Less than daily 7905 (9.69) 2224 (9.91)  Daily, intermittently 37 760 (46.28) 9556 (42.59)  Constantly 9203 (11.28) 2502 (11.15) Mental health  Exhibits anxiety symptoms 37 877 (46.43) 9607 (42.82) <.0001  Depression 3922 (4.81) 1027 (4.58) .1524 . TM . MA . . . No. (%) . No. (%) . P‡ . Cognitive function <.0001  Alert or oriented, able to focus and shift attention, comprehends and recalls task directions independently 50 760 (62.22) 14 976 (66.75)  Requires some prompting or assistance 29 256 (35.86) 7029 (31.33)  Requires considerable assistance or totally dependent 1571 (1.93) 431 (1.92) Cognitive, behavioral, and psychiatric symptoms  Memory deficit 9287 (11.38) 2376 (10.59) .0009  Impaired decision-making 11 900 (14.59) 2701 (12.04) <.0001  Verbal disruption, aggression, inappropriate behavior, delusional 1168 (1.43) 286 (1.28) .0763  None of above behaviors demonstrated 64 586 (79.16) 18 402 (82.02) <.0001 Needs assistance in activities of daily living  Grooming 60 872 (74.61) 15 841 (70.61) <.0001  Dressing§ 69 800 (85.55) 18 380 (81.92) <.0001  Bathing 77 666 (95.19) 20 953 (93.39) <.0001  Toileting transfer 49 804 (61.04) 12 858 (57.31) <.0001  Toileting hygiene 55 461 (67.98) 14 123 (62.95) <.0001  Transferring 65 637 (80.45) 17 381 (77.47) <.0001  Feeding 46 474 (56.96) 12 249 (54.60) <.0001  Ambulation or locomotion 71 873 (88.09) 19 182 (85.50) <.0001 Needs assistance in instrumental activities of daily living  Food preparation 67 522 (82.76) 18 323 (81.67) .0001  Use of phone 23 852 (29.24) 6092 (27.15) <.0001 Pain  None 18 429 (22.59) 5579 (24.87) <.0001  Present but does not interfere with activity 8290 (10.16) 2575 (11.48)  Less than daily 7905 (9.69) 2224 (9.91)  Daily, intermittently 37 760 (46.28) 9556 (42.59)  Constantly 9203 (11.28) 2502 (11.15) Mental health  Exhibits anxiety symptoms 37 877 (46.43) 9607 (42.82) <.0001  Depression 3922 (4.81) 1027 (4.58) .1524 * Home health use is defined as at least one OASIS assessment during the follow-up period. MA = Medicare Advantage; OASIS = Outcome and Assessment Information Set; SEER = Surveillance, Epidemiology, and End Results; TM = Traditional Medicare. † Three months following diagnosis includes the month of diagnosis plus an additional 3 months. ‡ Chi-squared tests of independence were used to assess the differences between MA and TM home health users. § Dressing is a combined item that reflects assistance in dressing upper (M1810) and/or lower (M1820) body. Open in new tab Table 3. Cognitive and physical function of SEER-Medicare patients with home health* use within 3 months† of cancer diagnosis, by Medicare benefit (2010–2013) . TM . MA . . . No. (%) . No. (%) . P‡ . Cognitive function <.0001  Alert or oriented, able to focus and shift attention, comprehends and recalls task directions independently 50 760 (62.22) 14 976 (66.75)  Requires some prompting or assistance 29 256 (35.86) 7029 (31.33)  Requires considerable assistance or totally dependent 1571 (1.93) 431 (1.92) Cognitive, behavioral, and psychiatric symptoms  Memory deficit 9287 (11.38) 2376 (10.59) .0009  Impaired decision-making 11 900 (14.59) 2701 (12.04) <.0001  Verbal disruption, aggression, inappropriate behavior, delusional 1168 (1.43) 286 (1.28) .0763  None of above behaviors demonstrated 64 586 (79.16) 18 402 (82.02) <.0001 Needs assistance in activities of daily living  Grooming 60 872 (74.61) 15 841 (70.61) <.0001  Dressing§ 69 800 (85.55) 18 380 (81.92) <.0001  Bathing 77 666 (95.19) 20 953 (93.39) <.0001  Toileting transfer 49 804 (61.04) 12 858 (57.31) <.0001  Toileting hygiene 55 461 (67.98) 14 123 (62.95) <.0001  Transferring 65 637 (80.45) 17 381 (77.47) <.0001  Feeding 46 474 (56.96) 12 249 (54.60) <.0001  Ambulation or locomotion 71 873 (88.09) 19 182 (85.50) <.0001 Needs assistance in instrumental activities of daily living  Food preparation 67 522 (82.76) 18 323 (81.67) .0001  Use of phone 23 852 (29.24) 6092 (27.15) <.0001 Pain  None 18 429 (22.59) 5579 (24.87) <.0001  Present but does not interfere with activity 8290 (10.16) 2575 (11.48)  Less than daily 7905 (9.69) 2224 (9.91)  Daily, intermittently 37 760 (46.28) 9556 (42.59)  Constantly 9203 (11.28) 2502 (11.15) Mental health  Exhibits anxiety symptoms 37 877 (46.43) 9607 (42.82) <.0001  Depression 3922 (4.81) 1027 (4.58) .1524 . TM . MA . . . No. (%) . No. (%) . P‡ . Cognitive function <.0001  Alert or oriented, able to focus and shift attention, comprehends and recalls task directions independently 50 760 (62.22) 14 976 (66.75)  Requires some prompting or assistance 29 256 (35.86) 7029 (31.33)  Requires considerable assistance or totally dependent 1571 (1.93) 431 (1.92) Cognitive, behavioral, and psychiatric symptoms  Memory deficit 9287 (11.38) 2376 (10.59) .0009  Impaired decision-making 11 900 (14.59) 2701 (12.04) <.0001  Verbal disruption, aggression, inappropriate behavior, delusional 1168 (1.43) 286 (1.28) .0763  None of above behaviors demonstrated 64 586 (79.16) 18 402 (82.02) <.0001 Needs assistance in activities of daily living  Grooming 60 872 (74.61) 15 841 (70.61) <.0001  Dressing§ 69 800 (85.55) 18 380 (81.92) <.0001  Bathing 77 666 (95.19) 20 953 (93.39) <.0001  Toileting transfer 49 804 (61.04) 12 858 (57.31) <.0001  Toileting hygiene 55 461 (67.98) 14 123 (62.95) <.0001  Transferring 65 637 (80.45) 17 381 (77.47) <.0001  Feeding 46 474 (56.96) 12 249 (54.60) <.0001  Ambulation or locomotion 71 873 (88.09) 19 182 (85.50) <.0001 Needs assistance in instrumental activities of daily living  Food preparation 67 522 (82.76) 18 323 (81.67) .0001  Use of phone 23 852 (29.24) 6092 (27.15) <.0001 Pain  None 18 429 (22.59) 5579 (24.87) <.0001  Present but does not interfere with activity 8290 (10.16) 2575 (11.48)  Less than daily 7905 (9.69) 2224 (9.91)  Daily, intermittently 37 760 (46.28) 9556 (42.59)  Constantly 9203 (11.28) 2502 (11.15) Mental health  Exhibits anxiety symptoms 37 877 (46.43) 9607 (42.82) <.0001  Depression 3922 (4.81) 1027 (4.58) .1524 * Home health use is defined as at least one OASIS assessment during the follow-up period. MA = Medicare Advantage; OASIS = Outcome and Assessment Information Set; SEER = Surveillance, Epidemiology, and End Results; TM = Traditional Medicare. † Three months following diagnosis includes the month of diagnosis plus an additional 3 months. ‡ Chi-squared tests of independence were used to assess the differences between MA and TM home health users. § Dressing is a combined item that reflects assistance in dressing upper (M1810) and/or lower (M1820) body. Open in new tab Most cancer patients receiving home health within 3 months of their cancer diagnosis received home health care after discharge from the hospital (Table 4). However, a larger share of MA patients received home health following a hospital stay compared with TM patients (64.5% compared with 62.4%). Additionally, a larger share of TM patients were admitted to home health directly from the community, without an inpatient stay in the last 14 days, than cancer patients with MA (15.7% compared with 14%, respectively). Cancer patients enrolled in TM had longer average and median lengths of home health service compared with MA enrollees (an average of 42.2 days compared with 39.4 days, respectively, and a median of 27 days compared with 26 days, respectively). Table 4. Admission source and length of service among SEER-Medicare patients with home health* use within 3 months† of cancer diagnosis, by Medicare benefit (2010–2013) . TM . MA . P‡ . Discharged in prior 2 wk from: no. (%)  >1 institution 2838 (3.48) 896 (4.0)  Acute care hospital 50 897 (62.38) 14 478 (64.5) <.0001  Rehab, long-term hospital, SNF 14 249 (17.46) 3698 (16.5)  Long-term nursing home, other, psychiatric 838 (1.03) 231 (1.0)  Not in a facility 12 765 (15.65) 3133 (14.0)  Length of service, mean (SD), d 42.24 (61.5) 39.44 (55.7) <.0001  Length of service, median (IQR), d 27 (42) 26 (42) . TM . MA . P‡ . Discharged in prior 2 wk from: no. (%)  >1 institution 2838 (3.48) 896 (4.0)  Acute care hospital 50 897 (62.38) 14 478 (64.5) <.0001  Rehab, long-term hospital, SNF 14 249 (17.46) 3698 (16.5)  Long-term nursing home, other, psychiatric 838 (1.03) 231 (1.0)  Not in a facility 12 765 (15.65) 3133 (14.0)  Length of service, mean (SD), d 42.24 (61.5) 39.44 (55.7) <.0001  Length of service, median (IQR), d 27 (42) 26 (42) * Home health use is defined as at least one OASIS assessment during the follow-up period. IQR = interquartile range; MA = Medicare Advantage; OASIS = Outcome and Assessment Information Set; SEER = Surveillance, Epidemiology, and End Results; SNF = skilled nursing facility; TM = Traditional Medicare; d = days † Three months following diagnosis includes the month of diagnosis plus an additional 3 months. ‡ Chi-squared tests of independence and t tests were used to assess the differences between MA and TM home health users. Open in new tab Table 4. Admission source and length of service among SEER-Medicare patients with home health* use within 3 months† of cancer diagnosis, by Medicare benefit (2010–2013) . TM . MA . P‡ . Discharged in prior 2 wk from: no. (%)  >1 institution 2838 (3.48) 896 (4.0)  Acute care hospital 50 897 (62.38) 14 478 (64.5) <.0001  Rehab, long-term hospital, SNF 14 249 (17.46) 3698 (16.5)  Long-term nursing home, other, psychiatric 838 (1.03) 231 (1.0)  Not in a facility 12 765 (15.65) 3133 (14.0)  Length of service, mean (SD), d 42.24 (61.5) 39.44 (55.7) <.0001  Length of service, median (IQR), d 27 (42) 26 (42) . TM . MA . P‡ . Discharged in prior 2 wk from: no. (%)  >1 institution 2838 (3.48) 896 (4.0)  Acute care hospital 50 897 (62.38) 14 478 (64.5) <.0001  Rehab, long-term hospital, SNF 14 249 (17.46) 3698 (16.5)  Long-term nursing home, other, psychiatric 838 (1.03) 231 (1.0)  Not in a facility 12 765 (15.65) 3133 (14.0)  Length of service, mean (SD), d 42.24 (61.5) 39.44 (55.7) <.0001  Length of service, median (IQR), d 27 (42) 26 (42) * Home health use is defined as at least one OASIS assessment during the follow-up period. IQR = interquartile range; MA = Medicare Advantage; OASIS = Outcome and Assessment Information Set; SEER = Surveillance, Epidemiology, and End Results; SNF = skilled nursing facility; TM = Traditional Medicare; d = days † Three months following diagnosis includes the month of diagnosis plus an additional 3 months. ‡ Chi-squared tests of independence and t tests were used to assess the differences between MA and TM home health users. Open in new tab Discussion In this study, we present information about MA and TM cancer patients who received home health in the 3 months following a cancer diagnosis using a new resource made available by NCI: SEER-Medicare data linked with the home health OASIS. We found that cancer patients who used home health in the 3 months following diagnosis tended to be older, have poorer HCC scores, and more advanced cancers, with similar characteristics for TM vs MA patients. Among cancer patients who received home health after their diagnosis, those enrolled in TM had increased cognitive impairment, physical limitations, presence of pain, and anxiety symptoms compared with cancer patients enrolled in MA. Recent studies, not specific to cancer, have observed statistically significant differences in the health status, use of postacute care, and outcomes between TM and MA beneficiaries (11–15). Research has shown that among all hospitalized patients, beneficiaries enrolled in MA are more likely to be discharged to home than to institutional postacute care compared with their TM counterparts (11). For patients discharged to home, only 11% of MA patients receive home health following a hospitalization compared with 16% of TM beneficiaries (11). Also, TM beneficiaries are more likely to use home health services and to use them for a longer duration than beneficiaries enrolled in MA (6). However, we do not know whether these differences in utilization of home health services between MA and TM exist among subgroups of patients, such as patients with a recent cancer diagnosis. Future work is needed that adjusts for differences in beneficiaries’ health and cancer characteristics that may account for differences in the rates of home health use following a cancer diagnosis. The newly linked SEER-Medicare-OASIS data can be used to address this question. Our findings provide further detail about the use of postacute home health among patients with cancer. Consistent with research conducted by Kenzik et al., our data suggest that older cancer patients in the SEER-Medicare data have higher rates of home health use than younger cancer patients (3). We observed this among those enrolled in both MA and TM. These newly linked SEER-Medicare-OASIS data combined with the SEER-Medicare-Nursing Home Minimum Data Set linked data (16) have the possibility to provide much deeper insight into the postacute utilization patterns and outcomes for older cancer patients, particularly among those enrolled in MA who have traditionally been excluded from studies examining postacute care using the SEER-Medicare data (2, 3, 17–19). Our findings set the stage for a number of follow-on studies that can be conducted with the SEER-Medicare-OASIS linked data. For example, we do not know what types of home health agencies are caring for MA and TM cancer patients and whether or how the type of agency translates to differences in patients’ outcomes. Previous work does suggest that MA beneficiaries go to lower quality nursing homes and home health agencies than TM enrollees (20, 21). Given that home health agency characteristics are related to patient outcomes (22), additional work is needed to understand the home health agency selection processes for MA and TM cancer patients and how selection of these agencies may affect their longer term outcomes. Other research made possible with these newly linked data includes understanding differences in home health use among cohorts of cancer patients, such as by treatment modality and stage of cancer diagnosis. These data can also be useful for understanding how combinations of postacute care (eg, receipt of home health following discharge from a skilled nursing facility) may result in differences in outcomes for cancer patients. There are several limitations to our study that must be considered when interpreting our findings. First, this was a descriptive study of differences in the use of home health between MA and TM and does not make any causal conclusions. There are many patient and home health agency characteristics that may affect our findings, which we did not adjust for in our analyses. Second, our sample of patients are limited to those who receive any home health within the 3 months following the month of cancer diagnosis. A prior analysis of postacute care use among SEER-Medicare cancer patients demonstrated that use of home health care was greatest in the first 100 days following surgery (3). However, not all of the patients in our analysis had cancer-directed surgery and not all home health use during this time period may have been directly related to the cancer diagnosis. Third, our findings do not account for differences in the period of exposure to home health after diagnosis. However, we did create rates adjusted for person months alive and enrolled in TM or MA and did not observe any differences from the raw percentages. For ease of presentation, we opted to display the raw, unadjusted percentages. Relatedly, some of the patients in our analysis received hospice care within 3 months of diagnosis, which may affect the receipt of home health services. However, we found that excluding hospice patients from our analysis did not have an impact on our results; thus, we did not exclude this population. There are also elements of our study design that relate to generalizability to the broader population of cancer patients. The SEER registries are population based; therefore, these findings reflect the characteristics of Medicare patients living in the SEER geographic areas. A prior study has reported that SEER-Medicare patients are representative of the US older population in terms of age, race, and sex, although these patients are less likely to live in rural areas than Medicare patients throughout the United States (23). In addition, our work is not generalizable to noncancer home health patients. It is possible that differences in MA and TM observed among this population of cancer patients may not be observed among beneficiaries with a different chronic disease. Finally, the SEER markets vary in their rates of MA penetration, as reflected in the distribution of MA and TM SEER-Medicare beneficiaries across these markets. This variation likely affects home health practice patterns across markets, as observed in prior studies (7). In conclusion, our study demonstrates the value of a new resource to understand the role of home health in the treatment and experience of older patients with cancer. Our research suggests that MA beneficiaries with cancer who use home health services have better cognitive and functional status than their TM counterparts, have lower rates of home health care utilization, and receive services for shorter amounts of time. More research is needed to understand why these differences exist and if they are associated with differences in outcomes. As MA continues to gain a larger share of the Medicare population, work is needed to better understand the experiences of care for specific subgroups of beneficiaries, including those with cancer. The newly created SEER-Medicare-OASIS database will be a valuable resource to address this and other questions related to home health care for cancer patients. These data can be accessed for SEER cancer patients on the SEER-Medicare website at https://healthcaredelivery.cancer.gov/seermedicare/. Notes Affiliations of authors: Center of Innovation in Long-Term Services and Supports, U.S. Department of Veterans Affairs Medical Center, Providence, RI, USA (KST); Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA (KST, MLS); Information Management Services, Inc, Calverton, MD, USA (EB, MJB); National Cancer Institute, Bethesda, MD, USA (DPW, ABM, JLW). The authors declare no conflicts of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, the National Cancer Institute, or the United States government. References 1 Medicare Payment Advisory Commission. Report to Congress, Medicare Payment Policy: Chapter 9, Home Health Care Services. 2017 . http://medpac.gov/docs/default-source/reports/mar17_entirereport.pdf. Accessed November 1, 2019. 2 Locher JL , Kilgore ML, Morrisey MA, Ritchie CS. Patterns and predictors of home health and hospice use by older adults with cancer . J Am Geriatr Soc . 2006 ; 54 ( 8 ): 1206 – 1211 . doi:10.1111/j.1532-5415.2006.00833.x. Google Scholar Crossref Search ADS PubMed WorldCat 3 Kenzik KM , Williams GR, Bhatia S, Balentine CJ. Post-acute care among older adults with stage I to III colorectal cancer . J Am Geriatr Soc . 2019 ; 67 ( 5 ): 937 – 944 . doi:10.1111/jgs.15680. Google Scholar Crossref Search ADS PubMed WorldCat 4 Jacobson G , Damico A, Neuman T. Medicare Advantage 2017 spotlight: enrollment market update. Kaiser Family Foundation. 2017 . https://www.kff.org/medicare/issue-brief/medicare-advantage-2017-spotlight-enrollment-market-update/. Accessed November 1, 2019. 5 Neuman P , Jacobson GA. Medicare Advantage checkup . N Engl J Med . 2018 ; 379 ( 22 ): 2163 – 2172 . doi:10.1056/NEJMhpr1804089. Google Scholar Crossref Search ADS PubMed WorldCat 6 Waxman DA , Min L, Setodji CM, Hanson M, Wenger NS, Ganz DA. Does Medicare Advantage enrollment affect home healthcare use? Am J Manag Care . 2016 ; 22 ( 11 ): 714 – 720 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 7 Li Q , Rahman M, Gozalo P, Keohane LM, Gold MR, Trivedi AN. Regional variations: the use of hospitals, home health, and skilled nursing in Traditional Medicare and Medicare Advantage . Health Aff (Millwood) . 2018 ; 37 ( 8 ): 1274 – 1281 . doi:10.1377/hlthaff.2018.0147. Google Scholar Crossref Search ADS PubMed WorldCat 8 Cubanski J , Neuman T, Freed M. Issue brief: the facts on Medicare spending and financing. Henry J. Kaiser Family Foundation. 2019 . https://www.kff.org/medicare/issue-brief/the-facts-on-medicare-spending-and-financing/. Accessed December 2, 2019. 9 Smith BD , Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. Future of cancer incidence in the United States: burdens upon an aging, changing nation . J Clin Oncol . 2009 ; 27 ( 17 ): 2758 – 2765 . doi:10.1200/J Clin Oncol.2008.20.8983. Google Scholar Crossref Search ADS PubMed WorldCat 10 National Cancer Institute. About the SEER Program. SEER. https://seer.cancer.gov/about/overview.html. Accessed February 25, 2019. 11 Avalere. Medicare Advantage achieves cost-effective care and better outcomes for beneficiaries with chronic conditions relative to fee-for-service Medicare. 2018 . https://avalere.com/press-releases/medicare-advantage-achieves-better-health-outcomes-and-lower-utilization-of-high-cost-services-compared-to-fee-for-service-medicare. Accessed December 2, 2019. 12 Beveridge RA , Mendes SM, Caplan A, et al. . Mortality differences between Traditional Medicare and Medicare Advantage: a risk-adjusted assessment using claims data . Inquiry . 2017 ; 54 : 46958017709103 .doi:10.1177/0046958017709103. Google Scholar PubMed OpenURL Placeholder Text WorldCat 13 Huckfeldt PJ , Escarce JJ, Rabideau B, Karaca-Mandic P, Sood N. Less intense postacute care, better outcomes for enrollees in Medicare Advantage than those in fee-for-service . Health Aff (Millwood) . 2017 ; 36 ( 1 ): 91 – 100 . doi:10.1377/hlthaff.2016.1027. Google Scholar Crossref Search ADS PubMed WorldCat 14 Kumar A , Rahman M, Trivedi AN, Resnik L, Gozalo P, Mor V. Comparing post-acute rehabilitation use, length of stay, and outcomes experienced by Medicare fee-for-service and Medicare Advantage beneficiaries with hip fracture in the United States: a secondary analysis of administrative data . PLoS Med . 2018 ; 15 ( 6 ): e1002592 . doi:10.1371/journal.pmed.1002592. Google Scholar Crossref Search ADS PubMed WorldCat 15 McWilliams JM , Hsu J, Newhouse JP. New risk-adjustment system was associated with reduced favorable selection in Medicare Advantage . Health Aff (Millwood) . 2012 ; 31 ( 12 ): 2630 – 2640 . doi:10.1377/hlthaff.2011.1344. Google Scholar Crossref Search ADS PubMed WorldCat 16 Thomas KS , Boyd E, Mariotto AB, Penn DC, Barrett MJ, Warren JL. New opportunities for cancer health services research linking the SEER-Medicare data to the nursing home minimum data set . Medical Care . 2018 ; 56 ( 12 ): e90 – e96 . doi:10.1097/MLR.0000000000000877. Google Scholar Crossref Search ADS PubMed WorldCat 17 Jacobs BL , Zhang Y, Tan HJ, Ye Z, Skolarus TA, Hollenbeck BK. Hospitalization trends after prostate and bladder surgery: implications of potential payment reforms . J Urol . 2013 ; 189 ( 1 ): 59 – 65 . doi:10.1016/j.juro.2012.08.182. Google Scholar Crossref Search ADS PubMed WorldCat 18 Lowrance WT , Eastham JA, Yee DS, et al. . Costs of medical care after open or minimally invasive prostate cancer surgery: a population-based analysis . Cancer . 2012 ; 118 ( 12 ): 3079 – 3086 . doi:10.1002/cncr.26609. Google Scholar Crossref Search ADS PubMed WorldCat 19 Li TT , Shore ND, Mehra M, et al. . Impact of subsequent metastases on costs and medical resource use for prostate cancer patients initially diagnosed with localized disease . Cancer . 2017 ; 123 ( 18 ): 3591 – 3601 . doi:10.1002/cncr.30784. Google Scholar Crossref Search ADS PubMed WorldCat 20 Meyers DJ , Mor V, Rahman M. Medicare Advantage enrollees more likely to enter lower-quality nursing homes compared to fee-for-service enrollees . Health Aff . 2018 ; 37 ( 1 ): 78 – 85 . doi:10.1377/hlthaff.2017.0714. Google Scholar Crossref Search ADS WorldCat 21 Schwartz ML , Kosar CM, Mroz TM, Kumar A, Rahman M. Quality of home health agencies serving Traditional Medicare vs Medicare Advantage beneficiaries . JAMA Netw Open . 2019 ; 2 ( 9 ): e1910622 .doi:10.1001/jamanetworkopen.2019.10622. Google Scholar Crossref Search ADS PubMed WorldCat 22 Mroz TM , Meadow A, Colantuoni E, Leff B, Wolff JL. Home health agency characteristics and quality outcomes for Medicare beneficiaries with rehabilitation-sensitive conditions . Arch Phys Med Rehabil . 2018 ; 99 ( 6 ): 1090 – 1098.e4 . doi:10.1016/j.apmr.2017.08.483. Google Scholar Crossref Search ADS PubMed WorldCat 23 Warren JL , Klabunde CN, Schrag D, Bach PB, Riley GF. Overview of the SEER-Medicare data: content, research applications, and generalizability to the United States elderly population . Med Care . 2002 ; 40(8 Suppl ): IV-3 – 18 . doi:10.1097/01.MLR.0000020942.47004.03. OpenURL Placeholder Text WorldCat © The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JNCI Monographs Oxford University Press

Home Health Use Following a Cancer Diagnosis Among Patients Enrolled in Medicare Advantage and Traditional Medicare: Findings From the Newly Linked SEER-Medicare and Home Health OASIS Data

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© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com
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1052-6773
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10.1093/jncimonographs/lgaa003
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Abstract

Abstract Background This article describes characteristics of patients receiving home health following an initial cancer diagnosis, comparing those enrolled in Medicare Advantage (MA) and Traditional Medicare (TM), using the newly linked 2010–2014 National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER)-Medicare and home health Outcome and Assessment Information Set (OASIS) data. Methods We identified SEER-Medicare beneficiaries with at least one OASIS assessment within 3 months of cancer diagnosis in 2010-2014, and summarized their demographic and clinical characteristics. Demographic and diagnostic data were obtained from the SEER-Medicare data, while further details about cognitive status, mood, function, and medical history were obtained from OASIS. We assessed differences between MA and TM beneficiaries using chi-square tests for independence, t-tests, and Kruskal-Wallis tests. Resutls We identified 104 023 patients who received home health within 3 months of cancer diagnosis: 81 587 enrolled in TM and 22 436 enrolled in MA. TM cancer patients had higher unadjusted rates of home health use than MA patients (16.3% vs 10.3%, P < .001). TM cancer patients receiving home health had more limitations in their cognitive function than their MA counterparts and longer lengths of service (mean = 42.2 days vs 39.4 days, P < .001; median = 27 vs 26 days, interquartile range = 42). Conclusion This study demonstrates the large number of cancer patients in the SEER-Medicare-OASIS data and describes characteristics for TM and MA patients. These newly linked data can be used to assess home health care among older patients with cancer. Home health care is an important part of our nation’s support system for the elderly, providing postacute and long-term care to approximately 3.5 million vulnerable Medicare beneficiaries (1). To be eligible for Medicare-reimbursed home health care, a beneficiary must need intermittent skilled care (<8 h/d) and be unable to leave home without considerable effort. Physicians must certify patients’ eligibility. Medicare patients with cancer can receive home health care in many stages of the cancer care continuum, ranging from services provided following initial cancer treatment to supportive care towards the end of life. A study using the linked National Cancer Institute’s (NCI) Surveillance, Epidemiology, and End Results (SEER)-Medicare claims data from the late 1990s found that 29% of Medicare cancer patients used home health following diagnosis, with 23% of Medicare cancer patients receiving home health services within 6 months of their cancer diagnosis (2). In contrast, only 7.8% of Medicare beneficiaries without cancer received home health services (2). In a more recent study using SEER-Medicare data, Medicare beneficiaries receiving surgery for stage III colorectal cancer had the highest cumulative incidence of home health care in the 100 days following surgery (19.4%) compared with cancer patients with stage I or II colorectal cancer (6.4%) and matched controls without cancer (2.8%) (3). Although these previous studies are informative in highlighting the role of home health in cancer care, they do not include information on home health care received among patients enrolled in Medicare’s managed care program, Medicare Advantage (MA) (4). In 2018, 34% of Medicare beneficiaries were enrolled in MA (5). The home health benefit varies greatly between Traditional Medicare (TM) and MA. In TM, home health is a covered benefit for homebound beneficiaries needing skilled care. There is no cost-sharing for home health, and before 2019, home health agencies received a prospective payment for a 60-day episode of care. In contrast to TM, MA plans are paid a capitated, risk-adjusted rate to cover Part A and B benefits for enrollees, including home health care. MA plans have flexibility to charge cost-sharing for home health, require prior authorization and reauthorization, conduct utilization review, and/or limit home health networks. MA has financial incentives to lower costs, which could result in either less home health care use among cancer patients (to limit home health spending) or greater use as an alternative to higher cost settings (eg, inpatient rehabilitation facilities, skilled nursing facilities). Previous research suggests MA enrollees use less home health care than their TM counterparts; however, this previous work has not focused on home health care for cancer patients. For example, Waxman et al. (6), used home health Outcome and Assessment Information Set (OASIS) assessment data, to model the probability of home health use, the duration of home health episodes, and clinical outcomes as a function of MA vs TM enrollment. After adjusting for demographic and clinical patient characteristics, the odds of receiving home health among TM enrollees were 1.83 times that of MA (95% confidence interval = 1.82 to 1.84) and home health duration was 34% longer for TM (95% confidence interval = 32% to 34%). However, outcomes differences were small in magnitude and inconsistent across measures. Li et al. observed that the use of home health care per 1000 beneficiary-years was 4712 days in MA and 7257 days in TM (absolute difference: 2545 days per 1000 beneficiary-years). Additional work also found that MA enrollees had less home health use (6.8% vs 9.4%) and for shorter durations (69.4 days vs 72.5 days) in 2016 than their TM counterparts (7). Given MA enrollment among Medicare beneficiaries is expected to increase (8), as is the number of older patients with cancer likely needing home health services (9), it is important to understand differences in the use of home care for cancer patients enrolled in TM and MA. In an effort to address gaps in our understanding of home health use for patients with cancer, the NCI has recently linked its SEER-Medicare files with the OASIS, a mandatory patient assessment instrument that is completed for all home health patients upon the start of home health care and at regular intervals thereafter. OASIS data are available for both TM and MA patients. Linkage of the SEER-Medicare data with the OASIS home health assessment data provides researchers with a rich data resource to assess the frequency of home health care use among Medicare beneficiaries with cancer enrolled in TM and MA, the characteristics of cancer patients receiving home health care, and their health outcomes. The objective of this article is to introduce the newly linked SEER-Medicare-OASIS data. We present the characteristics of Medicare beneficiaries with cancer, treated in the SEER registry areas, who received home health care within 3 months of diagnosis. For cancer patients enrolled in TM and MA, we describe differences in the rates of home health use, demographic characteristics, cognitive and physical function, and length of service separately. This information can be useful to understand the characteristics of TM and MA cancer patients who are receiving home health and sets the stage for future research examining access to home health and outcomes of cancer patients by Medicare benefit design. Methods Data Sources SEER-Medicare The assessment used the linked SEER-Medicare data. The SEER data (https://seer.cancer.gov) are obtained from population-based cancer registries that are funded by the NCI. The SEER registries include clinical information about all incident cancers occurring in patients living within defined geographic areas, representing over 30% of the US population (10). For each patient, the SEER data include demographic information including age, sex, and race; the number of primary incident cancers; month and year of diagnosis; site and stage of disease at diagnosis; type of surgery performed; and vital status. The Medicare data from the Centers for Medicare and Medicaid Services (CMS) include an enrollment file and unique Health Insurance Claim number for each Medicare beneficiary. Medicare claims are present for all inpatient hospitalizations, outpatient hospital services, physician services, durable medical equipment, skilled nursing, home care, and hospice services for beneficiaries with TM coverage. Prescription drug information is available for beneficiaries with TM or MA coverage who have enrolled in Medicare Part D. All Medicare claims include dates of service and codes for specific diagnoses, procedures, and medications. The SEER and Medicare data are linked biennially for 94% of patients over the age of 65 years at the time of cancer diagnosis. The version of SEER-Medicare data used in this article includes cancer cases diagnosed from 1973 to 2013 and Medicare claims through 2014. OASIS The Home Health OASIS is a standardized assessment of home health patients’ socio-demographic and environmental characteristics, health services utilization, physical and mental health, and physical and cognitive function. All Medicare or Medicaid-certified home health agencies in the United States (approximately 11 668 in 2018) are required to submit OASIS assessments for all patients age 18+ years receiving skilled home health services reimbursed by Medicaid or Medicare (including both MA and TM). These assessments are completed at the start of care, at the time of transfer to an inpatient facility (without discharge from the agency), at the resumption of care (after inpatient stay), at discharge or death, and for recertification of services at the end of the authorization period (60 days). OASIS version C (OASIS-C) was introduced in 2010 after field testing and examination of inter-rater reliability, validity, and usability. Linkage of SEER-Medicare Data to OASIS-C We used data from the OASIS-C for calendar years 2010 to 2014 linked to the SEER-Medicare data, which includes patients newly diagnosed with cancer in the SEER data from 2010 to 2013. The linkage was accomplished using a CMS file that cross-walks each cancer patient’s unique Health Insurance Claim number to their beneficiary identifier that is used to uniquely identify persons in the OASIS data. Of the 718 248 SEER-Medicare patients newly diagnosed with cancer between 2010 and 2013, 254 265 had an OASIS assessment at any point between 2010 and 2014. The NCI’s Institutional Review Board, CMS, and each of the SEER Registries approved linkage of SEER-Medicare and OASIS data. Analytic Samples and Analysis From the population of SEER-Medicare beneficiaries with at least one OASIS assessment over the period of 2010 to 2014, we identified those whose first OASIS assessment was within 3 months of the month of their cancer diagnosis. This time period was defined as the month of diagnosis and the 3 months after. This yielded 104 023 SEER-Medicare patients who newly received home health within this time period. Because most patients have multiple OASIS assessments over their home health episode, we included data from the first OASIS start-of-care assessment only. To address questions about differences in cancer patients who have TM vs MA coverage, we compared patient characteristics for all patients in the SEER-Medicare data. We also report on TM vs MA differences in select characteristics focusing only on those SEER-Medicare patients who were in the SEER-Medicare-OASIS data. Information obtained from the SEER-Medicare data included demographics, marital status, dual-eligibility for Medicaid, cancer site, date of diagnosis, and Hierarchical Conditions Classification (HCC) score. To gain further insight into home health users, we used information obtained from the OASIS assessment. We present patients’ cognitive status, mood, functional abilities, recent history of an inpatient episode, and length of home health service. Cognitive status was operationalized as the patient’s current (day of admission assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands. We also report if a patient exhibited any cognitive, behavioral, and psychiatric symptoms. We present the patient’s perceived anxiety and if they met the clinical criteria for depression using the Patient Health Questionnaire-2 (Sheeran). Functional impairment included measures of a patient’s need for assistance in activities of daily living (ie, grooming, dressing, bathing, toileting transfer, toileting hygiene, transferring, feeding, and ambulation/locomotion) or instrumental activities of daily living (ie, food preparation and use of the telephone). We also used the OASIS data to identify if the patient had been in a hospital or other institution in the 2 weeks before receiving home health care and the length of home health services. Length of service in home health was defined as the duration between the admission date and discharge date for each episode. For persons with concurrent episodes from distinct providers, we summed home health days across all home health providers. We summarized the characteristics of SEER-Medicare patients receiving home health services with standard descriptive measures including medians, means, SDs, frequencies, and proportions. Statistical significance of differences between MA and TM beneficiaries was evaluated using chi-square tests for independence, t tests, and Kruskal-Wallis tests, as appropriate. Results In Table 1, we compare the characteristics of all SEER-Medicare patients enrolled in MA compared with TM. The two groups of cancer patients were similar in sex, stage of cancer at diagnosis, and clinical complexity as measured by the HCC score. However, the two groups differed by geography and slightly in terms of age, with more TM patients belonging to both the youngest and oldest age groups. Notably, the two populations also differed by race and dual eligibility for Medicaid, with more racial and ethnic minorities enrolled in MA and more dually eligible in TM. Table 1. Characteristics of all SEER-Medicare patients and SEER-Medicare patients with home health use* within 3† months of cancer diagnosis, by Medicare benefit (2010–2013) . All SEER-Medicare patients . SEER-Medicare patients receiving home health care . Percent of SEER-Medicare patients receiving home health care‡ . . TM . MA . TM . MA . TM . MA . Sex No. (%) No. (%) No. (%) No. (%)  Male 254 672 (51) 109 832 (50) 35 849 (44) 9985 (45) 14% 9%  Female 245 329 (49) 108 415 (50) 45 738 (56) 12 451 (55) 19% 11% Race§  Non-Hispanic white 391 209 (78) 154 663 (71) 63 008 (77) 16 358 (73) 16% 11%  Non-Hispanic black 46 204 (9) 22 458 (10) 8798 (11) 2934 (13) 19% 13%  Hispanic 30 032 (6) 22 382 (10) 5441 (7) 1950 (9) 18% 9%  Asian or Pacific Islander 24 276 (5) 15 207 (7) 3928 (5) 1070 (5) 16% 7%  Other 8280 (2) 3837 (2) 412 (1) 124 (1) 5% 3% Age at diagnosis, y  <65 48 043 (10) 13 170 (6) 7178 (9) 1365 (6) 15% 10%  65–69 112 382 (22) 53 137 (24) 13 866 (17) 3938 (18) 12% 7%  70–74 105 040 (21) 50 266 (23) 15 157 (19) 4619 (21) 14% 9%  75–79 88 716 (18) 42 032 (19) 15 553 (19) 4652 (21) 18% 11%  80+ 145 820 (29) 59 642 (27) 29 833 (37) 7862 (35) 20% 13% Marital status  Married or partnered 212 029 (42) 84 974 (39) 35 980 (44) 10 574 (47) 17% 12%  Not married or not partnered 240 964 (48) 109.402 (50) 40 490 (50) 10 397 (46) 17% 10%  Unknown 47 008 (9) 23 871 (11) 5117 (6) 1465 (7) 11% 6% Dually eligible for Medicaid‖  Full 72 857 (15) 15 757 (7) 14 484 (18) 1839 (8) 20% 12%  Partial 21 577 (4) 9130 (4s) 4505 (6) 1549 (7) 21% 17% Registry  Connecticut 26 159 (5) 7887 (4) 6006 (7) 1203 (5) 23% 15%  Detroit 28 947 (6) 9673 (4) 5916 (7) 1502 (7) 20% 16%  Georgia (all 4)¶ 59 586 (12) 20 692 (9) 8300 (10) 2517 (11) 14% 12%  Greater California 95 300 (19) 62 973 (29) 14 147 (17) 5639 (25) 15% 9%  Hawaii 5262 (1) 5498 (3) 283 (0) 318 (1) 5% 6%  Iowa 26 949 (5) 4712 (2) 3218 (4) 577 (3) 12% 12%  Kentucky 41 369 (8) 10 264 (5) 6915 (8) 1496 (7) 17% 15%  Los Angeles 31 352 (6) 26 920 (12) 6705 (8) 1831 (8) 21% 7%  Louisiana 32 582 (7) 13 023 (6) 6110 (7) 1958 (9) 19% 15%  New Jersey 75 663 (15) 13 769 (6) 14 969 (18) 2105 (9) 20% 15%  New Mexico 10 867 (2) 4838 (2) 1535 (2) 522 (2) 14% 11%  San Francisco or San Jose 28 697 (6) 19 769 (9) 3865 (5) 1247 (6) 13% 6%  Seattle 27 640 (6) 12 468 (6) 2244 (3) 861 (4) 8% 7%  Utah 9628 (2) 5761 (3) 1374 (2) 660 (3) 14% 11% SEER summary  Stage at diagnosis   Missing 65 043 (13) 26 981 (12) 11 486 (14) 3210 (14) 18% 12%   In situ 41 188 (8) 17 769 (8) 2708 (3) 668 (3) 7% 4%   Local 185 977 (37) 85 056 (39) 23 186 (28) 6261 (28) 12% 7%   Regional 81 190 (16) 35 663 (16) 18 883 (23) 5269 (23) 23% 15%   Distant 98 995 (20) 42 147 (19) 22 308 (27) 6317 (28) 23% 15%   Unstaged 27 608 (6) 10 631 (5) 3016 (4) 711 (3) 11% 7%  HCC† score   Missing 233 (0) 50 (0) 13 (0) 1 (0) 6% 2%   <1 (good) 287 901 (58) 126 253 (58) 39 138 (48) 10 444 (47) 14% 8%   1-2 134 585 (27) 58 964 (27) 25 676 (31) 7054 (31) 19% 12%   >2 (poor) 77 282 (15) 32 980 (15) 16 760 (21) 4937 (22) 22% 15%  Year of SEER diagnosis   2010 128 468 (26) 52 209 (24) 21 630 (27) 5027 (22) 17% 10%   2011 126 835 (25) 53 602 (25) 21 014 (26) 5536 (25) 17% 10%   2012 124 248 (25) 54 579 (25) 20 629 (25) 6002 (27) 17% 11%   2013 120 450 (24) 57 857 (27) 18 314 (22) 5871 (26) 15% 10% . All SEER-Medicare patients . SEER-Medicare patients receiving home health care . Percent of SEER-Medicare patients receiving home health care‡ . . TM . MA . TM . MA . TM . MA . Sex No. (%) No. (%) No. (%) No. (%)  Male 254 672 (51) 109 832 (50) 35 849 (44) 9985 (45) 14% 9%  Female 245 329 (49) 108 415 (50) 45 738 (56) 12 451 (55) 19% 11% Race§  Non-Hispanic white 391 209 (78) 154 663 (71) 63 008 (77) 16 358 (73) 16% 11%  Non-Hispanic black 46 204 (9) 22 458 (10) 8798 (11) 2934 (13) 19% 13%  Hispanic 30 032 (6) 22 382 (10) 5441 (7) 1950 (9) 18% 9%  Asian or Pacific Islander 24 276 (5) 15 207 (7) 3928 (5) 1070 (5) 16% 7%  Other 8280 (2) 3837 (2) 412 (1) 124 (1) 5% 3% Age at diagnosis, y  <65 48 043 (10) 13 170 (6) 7178 (9) 1365 (6) 15% 10%  65–69 112 382 (22) 53 137 (24) 13 866 (17) 3938 (18) 12% 7%  70–74 105 040 (21) 50 266 (23) 15 157 (19) 4619 (21) 14% 9%  75–79 88 716 (18) 42 032 (19) 15 553 (19) 4652 (21) 18% 11%  80+ 145 820 (29) 59 642 (27) 29 833 (37) 7862 (35) 20% 13% Marital status  Married or partnered 212 029 (42) 84 974 (39) 35 980 (44) 10 574 (47) 17% 12%  Not married or not partnered 240 964 (48) 109.402 (50) 40 490 (50) 10 397 (46) 17% 10%  Unknown 47 008 (9) 23 871 (11) 5117 (6) 1465 (7) 11% 6% Dually eligible for Medicaid‖  Full 72 857 (15) 15 757 (7) 14 484 (18) 1839 (8) 20% 12%  Partial 21 577 (4) 9130 (4s) 4505 (6) 1549 (7) 21% 17% Registry  Connecticut 26 159 (5) 7887 (4) 6006 (7) 1203 (5) 23% 15%  Detroit 28 947 (6) 9673 (4) 5916 (7) 1502 (7) 20% 16%  Georgia (all 4)¶ 59 586 (12) 20 692 (9) 8300 (10) 2517 (11) 14% 12%  Greater California 95 300 (19) 62 973 (29) 14 147 (17) 5639 (25) 15% 9%  Hawaii 5262 (1) 5498 (3) 283 (0) 318 (1) 5% 6%  Iowa 26 949 (5) 4712 (2) 3218 (4) 577 (3) 12% 12%  Kentucky 41 369 (8) 10 264 (5) 6915 (8) 1496 (7) 17% 15%  Los Angeles 31 352 (6) 26 920 (12) 6705 (8) 1831 (8) 21% 7%  Louisiana 32 582 (7) 13 023 (6) 6110 (7) 1958 (9) 19% 15%  New Jersey 75 663 (15) 13 769 (6) 14 969 (18) 2105 (9) 20% 15%  New Mexico 10 867 (2) 4838 (2) 1535 (2) 522 (2) 14% 11%  San Francisco or San Jose 28 697 (6) 19 769 (9) 3865 (5) 1247 (6) 13% 6%  Seattle 27 640 (6) 12 468 (6) 2244 (3) 861 (4) 8% 7%  Utah 9628 (2) 5761 (3) 1374 (2) 660 (3) 14% 11% SEER summary  Stage at diagnosis   Missing 65 043 (13) 26 981 (12) 11 486 (14) 3210 (14) 18% 12%   In situ 41 188 (8) 17 769 (8) 2708 (3) 668 (3) 7% 4%   Local 185 977 (37) 85 056 (39) 23 186 (28) 6261 (28) 12% 7%   Regional 81 190 (16) 35 663 (16) 18 883 (23) 5269 (23) 23% 15%   Distant 98 995 (20) 42 147 (19) 22 308 (27) 6317 (28) 23% 15%   Unstaged 27 608 (6) 10 631 (5) 3016 (4) 711 (3) 11% 7%  HCC† score   Missing 233 (0) 50 (0) 13 (0) 1 (0) 6% 2%   <1 (good) 287 901 (58) 126 253 (58) 39 138 (48) 10 444 (47) 14% 8%   1-2 134 585 (27) 58 964 (27) 25 676 (31) 7054 (31) 19% 12%   >2 (poor) 77 282 (15) 32 980 (15) 16 760 (21) 4937 (22) 22% 15%  Year of SEER diagnosis   2010 128 468 (26) 52 209 (24) 21 630 (27) 5027 (22) 17% 10%   2011 126 835 (25) 53 602 (25) 21 014 (26) 5536 (25) 17% 10%   2012 124 248 (25) 54 579 (25) 20 629 (25) 6002 (27) 17% 11%   2013 120 450 (24) 57 857 (27) 18 314 (22) 5871 (26) 15% 10% * Home health use is defined as at least one OASIS assessment during the follow-up period. HCC = hierarchical conditions category; MA = Medicare Advantage; OASIS = Outcome and Assessment Information Set; SEER = Surveillance, Epidemiology, and End Results; TM = Traditional Medicare. † Three months following diagnosis includes the month of diagnosis plus an additional 3 months. ‡ Percent of SEER-Medicare patients receiving home health care is calculated as the row percent. For example, 23% of SEER-Medicare patients enrolled in TM and living in the Connecticut region received home health within 3 months of their diagnosis. § Race or ethnicity information comes from the SEER registry. ‖ Dually eligible during the month of cancer diagnosis. ¶ Georgia includes Atlanta, Greater Georgia, and Rural Georgia data. Open in new tab Table 1. Characteristics of all SEER-Medicare patients and SEER-Medicare patients with home health use* within 3† months of cancer diagnosis, by Medicare benefit (2010–2013) . All SEER-Medicare patients . SEER-Medicare patients receiving home health care . Percent of SEER-Medicare patients receiving home health care‡ . . TM . MA . TM . MA . TM . MA . Sex No. (%) No. (%) No. (%) No. (%)  Male 254 672 (51) 109 832 (50) 35 849 (44) 9985 (45) 14% 9%  Female 245 329 (49) 108 415 (50) 45 738 (56) 12 451 (55) 19% 11% Race§  Non-Hispanic white 391 209 (78) 154 663 (71) 63 008 (77) 16 358 (73) 16% 11%  Non-Hispanic black 46 204 (9) 22 458 (10) 8798 (11) 2934 (13) 19% 13%  Hispanic 30 032 (6) 22 382 (10) 5441 (7) 1950 (9) 18% 9%  Asian or Pacific Islander 24 276 (5) 15 207 (7) 3928 (5) 1070 (5) 16% 7%  Other 8280 (2) 3837 (2) 412 (1) 124 (1) 5% 3% Age at diagnosis, y  <65 48 043 (10) 13 170 (6) 7178 (9) 1365 (6) 15% 10%  65–69 112 382 (22) 53 137 (24) 13 866 (17) 3938 (18) 12% 7%  70–74 105 040 (21) 50 266 (23) 15 157 (19) 4619 (21) 14% 9%  75–79 88 716 (18) 42 032 (19) 15 553 (19) 4652 (21) 18% 11%  80+ 145 820 (29) 59 642 (27) 29 833 (37) 7862 (35) 20% 13% Marital status  Married or partnered 212 029 (42) 84 974 (39) 35 980 (44) 10 574 (47) 17% 12%  Not married or not partnered 240 964 (48) 109.402 (50) 40 490 (50) 10 397 (46) 17% 10%  Unknown 47 008 (9) 23 871 (11) 5117 (6) 1465 (7) 11% 6% Dually eligible for Medicaid‖  Full 72 857 (15) 15 757 (7) 14 484 (18) 1839 (8) 20% 12%  Partial 21 577 (4) 9130 (4s) 4505 (6) 1549 (7) 21% 17% Registry  Connecticut 26 159 (5) 7887 (4) 6006 (7) 1203 (5) 23% 15%  Detroit 28 947 (6) 9673 (4) 5916 (7) 1502 (7) 20% 16%  Georgia (all 4)¶ 59 586 (12) 20 692 (9) 8300 (10) 2517 (11) 14% 12%  Greater California 95 300 (19) 62 973 (29) 14 147 (17) 5639 (25) 15% 9%  Hawaii 5262 (1) 5498 (3) 283 (0) 318 (1) 5% 6%  Iowa 26 949 (5) 4712 (2) 3218 (4) 577 (3) 12% 12%  Kentucky 41 369 (8) 10 264 (5) 6915 (8) 1496 (7) 17% 15%  Los Angeles 31 352 (6) 26 920 (12) 6705 (8) 1831 (8) 21% 7%  Louisiana 32 582 (7) 13 023 (6) 6110 (7) 1958 (9) 19% 15%  New Jersey 75 663 (15) 13 769 (6) 14 969 (18) 2105 (9) 20% 15%  New Mexico 10 867 (2) 4838 (2) 1535 (2) 522 (2) 14% 11%  San Francisco or San Jose 28 697 (6) 19 769 (9) 3865 (5) 1247 (6) 13% 6%  Seattle 27 640 (6) 12 468 (6) 2244 (3) 861 (4) 8% 7%  Utah 9628 (2) 5761 (3) 1374 (2) 660 (3) 14% 11% SEER summary  Stage at diagnosis   Missing 65 043 (13) 26 981 (12) 11 486 (14) 3210 (14) 18% 12%   In situ 41 188 (8) 17 769 (8) 2708 (3) 668 (3) 7% 4%   Local 185 977 (37) 85 056 (39) 23 186 (28) 6261 (28) 12% 7%   Regional 81 190 (16) 35 663 (16) 18 883 (23) 5269 (23) 23% 15%   Distant 98 995 (20) 42 147 (19) 22 308 (27) 6317 (28) 23% 15%   Unstaged 27 608 (6) 10 631 (5) 3016 (4) 711 (3) 11% 7%  HCC† score   Missing 233 (0) 50 (0) 13 (0) 1 (0) 6% 2%   <1 (good) 287 901 (58) 126 253 (58) 39 138 (48) 10 444 (47) 14% 8%   1-2 134 585 (27) 58 964 (27) 25 676 (31) 7054 (31) 19% 12%   >2 (poor) 77 282 (15) 32 980 (15) 16 760 (21) 4937 (22) 22% 15%  Year of SEER diagnosis   2010 128 468 (26) 52 209 (24) 21 630 (27) 5027 (22) 17% 10%   2011 126 835 (25) 53 602 (25) 21 014 (26) 5536 (25) 17% 10%   2012 124 248 (25) 54 579 (25) 20 629 (25) 6002 (27) 17% 11%   2013 120 450 (24) 57 857 (27) 18 314 (22) 5871 (26) 15% 10% . All SEER-Medicare patients . SEER-Medicare patients receiving home health care . Percent of SEER-Medicare patients receiving home health care‡ . . TM . MA . TM . MA . TM . MA . Sex No. (%) No. (%) No. (%) No. (%)  Male 254 672 (51) 109 832 (50) 35 849 (44) 9985 (45) 14% 9%  Female 245 329 (49) 108 415 (50) 45 738 (56) 12 451 (55) 19% 11% Race§  Non-Hispanic white 391 209 (78) 154 663 (71) 63 008 (77) 16 358 (73) 16% 11%  Non-Hispanic black 46 204 (9) 22 458 (10) 8798 (11) 2934 (13) 19% 13%  Hispanic 30 032 (6) 22 382 (10) 5441 (7) 1950 (9) 18% 9%  Asian or Pacific Islander 24 276 (5) 15 207 (7) 3928 (5) 1070 (5) 16% 7%  Other 8280 (2) 3837 (2) 412 (1) 124 (1) 5% 3% Age at diagnosis, y  <65 48 043 (10) 13 170 (6) 7178 (9) 1365 (6) 15% 10%  65–69 112 382 (22) 53 137 (24) 13 866 (17) 3938 (18) 12% 7%  70–74 105 040 (21) 50 266 (23) 15 157 (19) 4619 (21) 14% 9%  75–79 88 716 (18) 42 032 (19) 15 553 (19) 4652 (21) 18% 11%  80+ 145 820 (29) 59 642 (27) 29 833 (37) 7862 (35) 20% 13% Marital status  Married or partnered 212 029 (42) 84 974 (39) 35 980 (44) 10 574 (47) 17% 12%  Not married or not partnered 240 964 (48) 109.402 (50) 40 490 (50) 10 397 (46) 17% 10%  Unknown 47 008 (9) 23 871 (11) 5117 (6) 1465 (7) 11% 6% Dually eligible for Medicaid‖  Full 72 857 (15) 15 757 (7) 14 484 (18) 1839 (8) 20% 12%  Partial 21 577 (4) 9130 (4s) 4505 (6) 1549 (7) 21% 17% Registry  Connecticut 26 159 (5) 7887 (4) 6006 (7) 1203 (5) 23% 15%  Detroit 28 947 (6) 9673 (4) 5916 (7) 1502 (7) 20% 16%  Georgia (all 4)¶ 59 586 (12) 20 692 (9) 8300 (10) 2517 (11) 14% 12%  Greater California 95 300 (19) 62 973 (29) 14 147 (17) 5639 (25) 15% 9%  Hawaii 5262 (1) 5498 (3) 283 (0) 318 (1) 5% 6%  Iowa 26 949 (5) 4712 (2) 3218 (4) 577 (3) 12% 12%  Kentucky 41 369 (8) 10 264 (5) 6915 (8) 1496 (7) 17% 15%  Los Angeles 31 352 (6) 26 920 (12) 6705 (8) 1831 (8) 21% 7%  Louisiana 32 582 (7) 13 023 (6) 6110 (7) 1958 (9) 19% 15%  New Jersey 75 663 (15) 13 769 (6) 14 969 (18) 2105 (9) 20% 15%  New Mexico 10 867 (2) 4838 (2) 1535 (2) 522 (2) 14% 11%  San Francisco or San Jose 28 697 (6) 19 769 (9) 3865 (5) 1247 (6) 13% 6%  Seattle 27 640 (6) 12 468 (6) 2244 (3) 861 (4) 8% 7%  Utah 9628 (2) 5761 (3) 1374 (2) 660 (3) 14% 11% SEER summary  Stage at diagnosis   Missing 65 043 (13) 26 981 (12) 11 486 (14) 3210 (14) 18% 12%   In situ 41 188 (8) 17 769 (8) 2708 (3) 668 (3) 7% 4%   Local 185 977 (37) 85 056 (39) 23 186 (28) 6261 (28) 12% 7%   Regional 81 190 (16) 35 663 (16) 18 883 (23) 5269 (23) 23% 15%   Distant 98 995 (20) 42 147 (19) 22 308 (27) 6317 (28) 23% 15%   Unstaged 27 608 (6) 10 631 (5) 3016 (4) 711 (3) 11% 7%  HCC† score   Missing 233 (0) 50 (0) 13 (0) 1 (0) 6% 2%   <1 (good) 287 901 (58) 126 253 (58) 39 138 (48) 10 444 (47) 14% 8%   1-2 134 585 (27) 58 964 (27) 25 676 (31) 7054 (31) 19% 12%   >2 (poor) 77 282 (15) 32 980 (15) 16 760 (21) 4937 (22) 22% 15%  Year of SEER diagnosis   2010 128 468 (26) 52 209 (24) 21 630 (27) 5027 (22) 17% 10%   2011 126 835 (25) 53 602 (25) 21 014 (26) 5536 (25) 17% 10%   2012 124 248 (25) 54 579 (25) 20 629 (25) 6002 (27) 17% 11%   2013 120 450 (24) 57 857 (27) 18 314 (22) 5871 (26) 15% 10% * Home health use is defined as at least one OASIS assessment during the follow-up period. HCC = hierarchical conditions category; MA = Medicare Advantage; OASIS = Outcome and Assessment Information Set; SEER = Surveillance, Epidemiology, and End Results; TM = Traditional Medicare. † Three months following diagnosis includes the month of diagnosis plus an additional 3 months. ‡ Percent of SEER-Medicare patients receiving home health care is calculated as the row percent. For example, 23% of SEER-Medicare patients enrolled in TM and living in the Connecticut region received home health within 3 months of their diagnosis. § Race or ethnicity information comes from the SEER registry. ‖ Dually eligible during the month of cancer diagnosis. ¶ Georgia includes Atlanta, Greater Georgia, and Rural Georgia data. Open in new tab Across all cancers, TM cancer patients had higher rates of home health use in the 3 months following a cancer diagnosis than MA patients with cancer (16.3% compared with 10.3%) (Table 1). Compared with MA patients, TM patients receiving home health were more likely to be white, younger than 65 years and older than 80 years old, not married or no partner, and dually eligible for Medicaid. Utilization differences between MA and TM varied by geographic location: the largest share of SEER-Medicare TM beneficiaries receiving home health were in New Jersey and the Greater California registries, whereas the largest share of MA beneficiaries were in the Greater California and Georgia registries. Patients in Hawaii and Seattle had the lowest rates of home health use regardless of their Medicare enrollment. Patients who had cancers with the highest incidence, including lung, breast, and colorectal, also constituted the largest group of patients using HH. However, patients with cancers that have a poor prognosis, such as ovarian and pancreatic, also frequently received home health care (Table 2). From the OASIS assessment, we observed that cancer patients enrolled in TM and receiving home health within 3 months of their cancer diagnosis were more likely to have limitations in their cognitive function as well as to suffer from memory deficits and impaired decision-making (Table 3) than their MA counterparts. Furthermore, they were more likely to require assistance in all their activities and instrumental activities of daily living. Regardless of enrollment status, more than 90% of cancer patients receiving home health within 3 months of their cancer diagnosis required assistance with bathing, over 85% needed assistance with ambulation/locomotion, and more than 80% needed assistance with dressing and preparing meals. TM cancer patients receiving home health during this time period were more likely to experience constant or daily, intermittent pain than those enrolled in MA (P = .001) and more likely to exhibit anxiety symptoms. There were no differences in depression between MA and TM. Table 2. Frequency of home health* use within 3† months of diagnosis among SEER‡-Medicare patients diagnosed with cancer, by cancer site and Medicare benefit (2010–2013) . SEER-Medicare patients diagnosed with cancer, No. . SEER-Medicare patients who used home health* in the 3 months following cancer diagnosis, No. . SEER cancer type . TM . MA . TM . MA . . No. . No. . No. (%) . No. (%) . Bladder 25 002 10 726 3668 (14.7) 1068 (10.0) Breast 63 145 30 458 8132 (12.9) 1926 (6.3) Colorectal 43 341 19 313 11 527 (26.6) 3193 (16.5) Kidney (RCC‡) 14 730 6186 2666 (18.1) 745 (12.0) Leukemias 12 565 5150 1738 (13.8) 460 (8.9) Lung 73 336 29 730 15 420 (21.0) 4211 (14.2) Multiple cancers§ 7495 2980 1716 (22.9) 461 (15.5) Non-Hodgkin’s lymphoma 19 190 8330 3145 (16.4) 910 (10.9) Other cancers§ 133 997 56 289 22 483 (16.8) 6469 (11.5) Ovarian 5747 2572 1577 (27.4) 451 (17.5) Pancreatic 15 981 6968 3640 (22.8) 973 (14.0) Prostate 66 237 30 946 3255 (4.9) 816 (2.6) Thyroid 5644 2255 370 (6.6) 116 (5.1) Uterine 13 591 6344 2250 (16.6) 637 (10.0) Total 500 001 218 247 81 587 (16.3) 22 436 (10.3) . SEER-Medicare patients diagnosed with cancer, No. . SEER-Medicare patients who used home health* in the 3 months following cancer diagnosis, No. . SEER cancer type . TM . MA . TM . MA . . No. . No. . No. (%) . No. (%) . Bladder 25 002 10 726 3668 (14.7) 1068 (10.0) Breast 63 145 30 458 8132 (12.9) 1926 (6.3) Colorectal 43 341 19 313 11 527 (26.6) 3193 (16.5) Kidney (RCC‡) 14 730 6186 2666 (18.1) 745 (12.0) Leukemias 12 565 5150 1738 (13.8) 460 (8.9) Lung 73 336 29 730 15 420 (21.0) 4211 (14.2) Multiple cancers§ 7495 2980 1716 (22.9) 461 (15.5) Non-Hodgkin’s lymphoma 19 190 8330 3145 (16.4) 910 (10.9) Other cancers§ 133 997 56 289 22 483 (16.8) 6469 (11.5) Ovarian 5747 2572 1577 (27.4) 451 (17.5) Pancreatic 15 981 6968 3640 (22.8) 973 (14.0) Prostate 66 237 30 946 3255 (4.9) 816 (2.6) Thyroid 5644 2255 370 (6.6) 116 (5.1) Uterine 13 591 6344 2250 (16.6) 637 (10.0) Total 500 001 218 247 81 587 (16.3) 22 436 (10.3) * Home health use is defined as at least one OASIS assessment during the follow-up period. MA = Medicare Advantage; OASIS = Outcome and Assessment Information Set; RCC = renal cell carcinoma; SEER = Surveillance, Epidemiology, and End Results; TM = Traditional Medicare. † Three months following diagnosis includes the month of diagnosis plus an additional 3 months. ‡ Renal cell carcinoma. § Multiple cancers refers to individuals who were diagnosed with more than one cancer. Other cancers include cancers of the anus, bone and joint, brain and other nervous system, cervix uteri, esophagus, larynx, liver, Hodgkin’s lymphoma, melanoma, myeloma, oral cavity and pharynx, small intestine, stomach, testis, and vulva. Open in new tab Table 2. Frequency of home health* use within 3† months of diagnosis among SEER‡-Medicare patients diagnosed with cancer, by cancer site and Medicare benefit (2010–2013) . SEER-Medicare patients diagnosed with cancer, No. . SEER-Medicare patients who used home health* in the 3 months following cancer diagnosis, No. . SEER cancer type . TM . MA . TM . MA . . No. . No. . No. (%) . No. (%) . Bladder 25 002 10 726 3668 (14.7) 1068 (10.0) Breast 63 145 30 458 8132 (12.9) 1926 (6.3) Colorectal 43 341 19 313 11 527 (26.6) 3193 (16.5) Kidney (RCC‡) 14 730 6186 2666 (18.1) 745 (12.0) Leukemias 12 565 5150 1738 (13.8) 460 (8.9) Lung 73 336 29 730 15 420 (21.0) 4211 (14.2) Multiple cancers§ 7495 2980 1716 (22.9) 461 (15.5) Non-Hodgkin’s lymphoma 19 190 8330 3145 (16.4) 910 (10.9) Other cancers§ 133 997 56 289 22 483 (16.8) 6469 (11.5) Ovarian 5747 2572 1577 (27.4) 451 (17.5) Pancreatic 15 981 6968 3640 (22.8) 973 (14.0) Prostate 66 237 30 946 3255 (4.9) 816 (2.6) Thyroid 5644 2255 370 (6.6) 116 (5.1) Uterine 13 591 6344 2250 (16.6) 637 (10.0) Total 500 001 218 247 81 587 (16.3) 22 436 (10.3) . SEER-Medicare patients diagnosed with cancer, No. . SEER-Medicare patients who used home health* in the 3 months following cancer diagnosis, No. . SEER cancer type . TM . MA . TM . MA . . No. . No. . No. (%) . No. (%) . Bladder 25 002 10 726 3668 (14.7) 1068 (10.0) Breast 63 145 30 458 8132 (12.9) 1926 (6.3) Colorectal 43 341 19 313 11 527 (26.6) 3193 (16.5) Kidney (RCC‡) 14 730 6186 2666 (18.1) 745 (12.0) Leukemias 12 565 5150 1738 (13.8) 460 (8.9) Lung 73 336 29 730 15 420 (21.0) 4211 (14.2) Multiple cancers§ 7495 2980 1716 (22.9) 461 (15.5) Non-Hodgkin’s lymphoma 19 190 8330 3145 (16.4) 910 (10.9) Other cancers§ 133 997 56 289 22 483 (16.8) 6469 (11.5) Ovarian 5747 2572 1577 (27.4) 451 (17.5) Pancreatic 15 981 6968 3640 (22.8) 973 (14.0) Prostate 66 237 30 946 3255 (4.9) 816 (2.6) Thyroid 5644 2255 370 (6.6) 116 (5.1) Uterine 13 591 6344 2250 (16.6) 637 (10.0) Total 500 001 218 247 81 587 (16.3) 22 436 (10.3) * Home health use is defined as at least one OASIS assessment during the follow-up period. MA = Medicare Advantage; OASIS = Outcome and Assessment Information Set; RCC = renal cell carcinoma; SEER = Surveillance, Epidemiology, and End Results; TM = Traditional Medicare. † Three months following diagnosis includes the month of diagnosis plus an additional 3 months. ‡ Renal cell carcinoma. § Multiple cancers refers to individuals who were diagnosed with more than one cancer. Other cancers include cancers of the anus, bone and joint, brain and other nervous system, cervix uteri, esophagus, larynx, liver, Hodgkin’s lymphoma, melanoma, myeloma, oral cavity and pharynx, small intestine, stomach, testis, and vulva. Open in new tab Table 3. Cognitive and physical function of SEER-Medicare patients with home health* use within 3 months† of cancer diagnosis, by Medicare benefit (2010–2013) . TM . MA . . . No. (%) . No. (%) . P‡ . Cognitive function <.0001  Alert or oriented, able to focus and shift attention, comprehends and recalls task directions independently 50 760 (62.22) 14 976 (66.75)  Requires some prompting or assistance 29 256 (35.86) 7029 (31.33)  Requires considerable assistance or totally dependent 1571 (1.93) 431 (1.92) Cognitive, behavioral, and psychiatric symptoms  Memory deficit 9287 (11.38) 2376 (10.59) .0009  Impaired decision-making 11 900 (14.59) 2701 (12.04) <.0001  Verbal disruption, aggression, inappropriate behavior, delusional 1168 (1.43) 286 (1.28) .0763  None of above behaviors demonstrated 64 586 (79.16) 18 402 (82.02) <.0001 Needs assistance in activities of daily living  Grooming 60 872 (74.61) 15 841 (70.61) <.0001  Dressing§ 69 800 (85.55) 18 380 (81.92) <.0001  Bathing 77 666 (95.19) 20 953 (93.39) <.0001  Toileting transfer 49 804 (61.04) 12 858 (57.31) <.0001  Toileting hygiene 55 461 (67.98) 14 123 (62.95) <.0001  Transferring 65 637 (80.45) 17 381 (77.47) <.0001  Feeding 46 474 (56.96) 12 249 (54.60) <.0001  Ambulation or locomotion 71 873 (88.09) 19 182 (85.50) <.0001 Needs assistance in instrumental activities of daily living  Food preparation 67 522 (82.76) 18 323 (81.67) .0001  Use of phone 23 852 (29.24) 6092 (27.15) <.0001 Pain  None 18 429 (22.59) 5579 (24.87) <.0001  Present but does not interfere with activity 8290 (10.16) 2575 (11.48)  Less than daily 7905 (9.69) 2224 (9.91)  Daily, intermittently 37 760 (46.28) 9556 (42.59)  Constantly 9203 (11.28) 2502 (11.15) Mental health  Exhibits anxiety symptoms 37 877 (46.43) 9607 (42.82) <.0001  Depression 3922 (4.81) 1027 (4.58) .1524 . TM . MA . . . No. (%) . No. (%) . P‡ . Cognitive function <.0001  Alert or oriented, able to focus and shift attention, comprehends and recalls task directions independently 50 760 (62.22) 14 976 (66.75)  Requires some prompting or assistance 29 256 (35.86) 7029 (31.33)  Requires considerable assistance or totally dependent 1571 (1.93) 431 (1.92) Cognitive, behavioral, and psychiatric symptoms  Memory deficit 9287 (11.38) 2376 (10.59) .0009  Impaired decision-making 11 900 (14.59) 2701 (12.04) <.0001  Verbal disruption, aggression, inappropriate behavior, delusional 1168 (1.43) 286 (1.28) .0763  None of above behaviors demonstrated 64 586 (79.16) 18 402 (82.02) <.0001 Needs assistance in activities of daily living  Grooming 60 872 (74.61) 15 841 (70.61) <.0001  Dressing§ 69 800 (85.55) 18 380 (81.92) <.0001  Bathing 77 666 (95.19) 20 953 (93.39) <.0001  Toileting transfer 49 804 (61.04) 12 858 (57.31) <.0001  Toileting hygiene 55 461 (67.98) 14 123 (62.95) <.0001  Transferring 65 637 (80.45) 17 381 (77.47) <.0001  Feeding 46 474 (56.96) 12 249 (54.60) <.0001  Ambulation or locomotion 71 873 (88.09) 19 182 (85.50) <.0001 Needs assistance in instrumental activities of daily living  Food preparation 67 522 (82.76) 18 323 (81.67) .0001  Use of phone 23 852 (29.24) 6092 (27.15) <.0001 Pain  None 18 429 (22.59) 5579 (24.87) <.0001  Present but does not interfere with activity 8290 (10.16) 2575 (11.48)  Less than daily 7905 (9.69) 2224 (9.91)  Daily, intermittently 37 760 (46.28) 9556 (42.59)  Constantly 9203 (11.28) 2502 (11.15) Mental health  Exhibits anxiety symptoms 37 877 (46.43) 9607 (42.82) <.0001  Depression 3922 (4.81) 1027 (4.58) .1524 * Home health use is defined as at least one OASIS assessment during the follow-up period. MA = Medicare Advantage; OASIS = Outcome and Assessment Information Set; SEER = Surveillance, Epidemiology, and End Results; TM = Traditional Medicare. † Three months following diagnosis includes the month of diagnosis plus an additional 3 months. ‡ Chi-squared tests of independence were used to assess the differences between MA and TM home health users. § Dressing is a combined item that reflects assistance in dressing upper (M1810) and/or lower (M1820) body. Open in new tab Table 3. Cognitive and physical function of SEER-Medicare patients with home health* use within 3 months† of cancer diagnosis, by Medicare benefit (2010–2013) . TM . MA . . . No. (%) . No. (%) . P‡ . Cognitive function <.0001  Alert or oriented, able to focus and shift attention, comprehends and recalls task directions independently 50 760 (62.22) 14 976 (66.75)  Requires some prompting or assistance 29 256 (35.86) 7029 (31.33)  Requires considerable assistance or totally dependent 1571 (1.93) 431 (1.92) Cognitive, behavioral, and psychiatric symptoms  Memory deficit 9287 (11.38) 2376 (10.59) .0009  Impaired decision-making 11 900 (14.59) 2701 (12.04) <.0001  Verbal disruption, aggression, inappropriate behavior, delusional 1168 (1.43) 286 (1.28) .0763  None of above behaviors demonstrated 64 586 (79.16) 18 402 (82.02) <.0001 Needs assistance in activities of daily living  Grooming 60 872 (74.61) 15 841 (70.61) <.0001  Dressing§ 69 800 (85.55) 18 380 (81.92) <.0001  Bathing 77 666 (95.19) 20 953 (93.39) <.0001  Toileting transfer 49 804 (61.04) 12 858 (57.31) <.0001  Toileting hygiene 55 461 (67.98) 14 123 (62.95) <.0001  Transferring 65 637 (80.45) 17 381 (77.47) <.0001  Feeding 46 474 (56.96) 12 249 (54.60) <.0001  Ambulation or locomotion 71 873 (88.09) 19 182 (85.50) <.0001 Needs assistance in instrumental activities of daily living  Food preparation 67 522 (82.76) 18 323 (81.67) .0001  Use of phone 23 852 (29.24) 6092 (27.15) <.0001 Pain  None 18 429 (22.59) 5579 (24.87) <.0001  Present but does not interfere with activity 8290 (10.16) 2575 (11.48)  Less than daily 7905 (9.69) 2224 (9.91)  Daily, intermittently 37 760 (46.28) 9556 (42.59)  Constantly 9203 (11.28) 2502 (11.15) Mental health  Exhibits anxiety symptoms 37 877 (46.43) 9607 (42.82) <.0001  Depression 3922 (4.81) 1027 (4.58) .1524 . TM . MA . . . No. (%) . No. (%) . P‡ . Cognitive function <.0001  Alert or oriented, able to focus and shift attention, comprehends and recalls task directions independently 50 760 (62.22) 14 976 (66.75)  Requires some prompting or assistance 29 256 (35.86) 7029 (31.33)  Requires considerable assistance or totally dependent 1571 (1.93) 431 (1.92) Cognitive, behavioral, and psychiatric symptoms  Memory deficit 9287 (11.38) 2376 (10.59) .0009  Impaired decision-making 11 900 (14.59) 2701 (12.04) <.0001  Verbal disruption, aggression, inappropriate behavior, delusional 1168 (1.43) 286 (1.28) .0763  None of above behaviors demonstrated 64 586 (79.16) 18 402 (82.02) <.0001 Needs assistance in activities of daily living  Grooming 60 872 (74.61) 15 841 (70.61) <.0001  Dressing§ 69 800 (85.55) 18 380 (81.92) <.0001  Bathing 77 666 (95.19) 20 953 (93.39) <.0001  Toileting transfer 49 804 (61.04) 12 858 (57.31) <.0001  Toileting hygiene 55 461 (67.98) 14 123 (62.95) <.0001  Transferring 65 637 (80.45) 17 381 (77.47) <.0001  Feeding 46 474 (56.96) 12 249 (54.60) <.0001  Ambulation or locomotion 71 873 (88.09) 19 182 (85.50) <.0001 Needs assistance in instrumental activities of daily living  Food preparation 67 522 (82.76) 18 323 (81.67) .0001  Use of phone 23 852 (29.24) 6092 (27.15) <.0001 Pain  None 18 429 (22.59) 5579 (24.87) <.0001  Present but does not interfere with activity 8290 (10.16) 2575 (11.48)  Less than daily 7905 (9.69) 2224 (9.91)  Daily, intermittently 37 760 (46.28) 9556 (42.59)  Constantly 9203 (11.28) 2502 (11.15) Mental health  Exhibits anxiety symptoms 37 877 (46.43) 9607 (42.82) <.0001  Depression 3922 (4.81) 1027 (4.58) .1524 * Home health use is defined as at least one OASIS assessment during the follow-up period. MA = Medicare Advantage; OASIS = Outcome and Assessment Information Set; SEER = Surveillance, Epidemiology, and End Results; TM = Traditional Medicare. † Three months following diagnosis includes the month of diagnosis plus an additional 3 months. ‡ Chi-squared tests of independence were used to assess the differences between MA and TM home health users. § Dressing is a combined item that reflects assistance in dressing upper (M1810) and/or lower (M1820) body. Open in new tab Most cancer patients receiving home health within 3 months of their cancer diagnosis received home health care after discharge from the hospital (Table 4). However, a larger share of MA patients received home health following a hospital stay compared with TM patients (64.5% compared with 62.4%). Additionally, a larger share of TM patients were admitted to home health directly from the community, without an inpatient stay in the last 14 days, than cancer patients with MA (15.7% compared with 14%, respectively). Cancer patients enrolled in TM had longer average and median lengths of home health service compared with MA enrollees (an average of 42.2 days compared with 39.4 days, respectively, and a median of 27 days compared with 26 days, respectively). Table 4. Admission source and length of service among SEER-Medicare patients with home health* use within 3 months† of cancer diagnosis, by Medicare benefit (2010–2013) . TM . MA . P‡ . Discharged in prior 2 wk from: no. (%)  >1 institution 2838 (3.48) 896 (4.0)  Acute care hospital 50 897 (62.38) 14 478 (64.5) <.0001  Rehab, long-term hospital, SNF 14 249 (17.46) 3698 (16.5)  Long-term nursing home, other, psychiatric 838 (1.03) 231 (1.0)  Not in a facility 12 765 (15.65) 3133 (14.0)  Length of service, mean (SD), d 42.24 (61.5) 39.44 (55.7) <.0001  Length of service, median (IQR), d 27 (42) 26 (42) . TM . MA . P‡ . Discharged in prior 2 wk from: no. (%)  >1 institution 2838 (3.48) 896 (4.0)  Acute care hospital 50 897 (62.38) 14 478 (64.5) <.0001  Rehab, long-term hospital, SNF 14 249 (17.46) 3698 (16.5)  Long-term nursing home, other, psychiatric 838 (1.03) 231 (1.0)  Not in a facility 12 765 (15.65) 3133 (14.0)  Length of service, mean (SD), d 42.24 (61.5) 39.44 (55.7) <.0001  Length of service, median (IQR), d 27 (42) 26 (42) * Home health use is defined as at least one OASIS assessment during the follow-up period. IQR = interquartile range; MA = Medicare Advantage; OASIS = Outcome and Assessment Information Set; SEER = Surveillance, Epidemiology, and End Results; SNF = skilled nursing facility; TM = Traditional Medicare; d = days † Three months following diagnosis includes the month of diagnosis plus an additional 3 months. ‡ Chi-squared tests of independence and t tests were used to assess the differences between MA and TM home health users. Open in new tab Table 4. Admission source and length of service among SEER-Medicare patients with home health* use within 3 months† of cancer diagnosis, by Medicare benefit (2010–2013) . TM . MA . P‡ . Discharged in prior 2 wk from: no. (%)  >1 institution 2838 (3.48) 896 (4.0)  Acute care hospital 50 897 (62.38) 14 478 (64.5) <.0001  Rehab, long-term hospital, SNF 14 249 (17.46) 3698 (16.5)  Long-term nursing home, other, psychiatric 838 (1.03) 231 (1.0)  Not in a facility 12 765 (15.65) 3133 (14.0)  Length of service, mean (SD), d 42.24 (61.5) 39.44 (55.7) <.0001  Length of service, median (IQR), d 27 (42) 26 (42) . TM . MA . P‡ . Discharged in prior 2 wk from: no. (%)  >1 institution 2838 (3.48) 896 (4.0)  Acute care hospital 50 897 (62.38) 14 478 (64.5) <.0001  Rehab, long-term hospital, SNF 14 249 (17.46) 3698 (16.5)  Long-term nursing home, other, psychiatric 838 (1.03) 231 (1.0)  Not in a facility 12 765 (15.65) 3133 (14.0)  Length of service, mean (SD), d 42.24 (61.5) 39.44 (55.7) <.0001  Length of service, median (IQR), d 27 (42) 26 (42) * Home health use is defined as at least one OASIS assessment during the follow-up period. IQR = interquartile range; MA = Medicare Advantage; OASIS = Outcome and Assessment Information Set; SEER = Surveillance, Epidemiology, and End Results; SNF = skilled nursing facility; TM = Traditional Medicare; d = days † Three months following diagnosis includes the month of diagnosis plus an additional 3 months. ‡ Chi-squared tests of independence and t tests were used to assess the differences between MA and TM home health users. Open in new tab Discussion In this study, we present information about MA and TM cancer patients who received home health in the 3 months following a cancer diagnosis using a new resource made available by NCI: SEER-Medicare data linked with the home health OASIS. We found that cancer patients who used home health in the 3 months following diagnosis tended to be older, have poorer HCC scores, and more advanced cancers, with similar characteristics for TM vs MA patients. Among cancer patients who received home health after their diagnosis, those enrolled in TM had increased cognitive impairment, physical limitations, presence of pain, and anxiety symptoms compared with cancer patients enrolled in MA. Recent studies, not specific to cancer, have observed statistically significant differences in the health status, use of postacute care, and outcomes between TM and MA beneficiaries (11–15). Research has shown that among all hospitalized patients, beneficiaries enrolled in MA are more likely to be discharged to home than to institutional postacute care compared with their TM counterparts (11). For patients discharged to home, only 11% of MA patients receive home health following a hospitalization compared with 16% of TM beneficiaries (11). Also, TM beneficiaries are more likely to use home health services and to use them for a longer duration than beneficiaries enrolled in MA (6). However, we do not know whether these differences in utilization of home health services between MA and TM exist among subgroups of patients, such as patients with a recent cancer diagnosis. Future work is needed that adjusts for differences in beneficiaries’ health and cancer characteristics that may account for differences in the rates of home health use following a cancer diagnosis. The newly linked SEER-Medicare-OASIS data can be used to address this question. Our findings provide further detail about the use of postacute home health among patients with cancer. Consistent with research conducted by Kenzik et al., our data suggest that older cancer patients in the SEER-Medicare data have higher rates of home health use than younger cancer patients (3). We observed this among those enrolled in both MA and TM. These newly linked SEER-Medicare-OASIS data combined with the SEER-Medicare-Nursing Home Minimum Data Set linked data (16) have the possibility to provide much deeper insight into the postacute utilization patterns and outcomes for older cancer patients, particularly among those enrolled in MA who have traditionally been excluded from studies examining postacute care using the SEER-Medicare data (2, 3, 17–19). Our findings set the stage for a number of follow-on studies that can be conducted with the SEER-Medicare-OASIS linked data. For example, we do not know what types of home health agencies are caring for MA and TM cancer patients and whether or how the type of agency translates to differences in patients’ outcomes. Previous work does suggest that MA beneficiaries go to lower quality nursing homes and home health agencies than TM enrollees (20, 21). Given that home health agency characteristics are related to patient outcomes (22), additional work is needed to understand the home health agency selection processes for MA and TM cancer patients and how selection of these agencies may affect their longer term outcomes. Other research made possible with these newly linked data includes understanding differences in home health use among cohorts of cancer patients, such as by treatment modality and stage of cancer diagnosis. These data can also be useful for understanding how combinations of postacute care (eg, receipt of home health following discharge from a skilled nursing facility) may result in differences in outcomes for cancer patients. There are several limitations to our study that must be considered when interpreting our findings. First, this was a descriptive study of differences in the use of home health between MA and TM and does not make any causal conclusions. There are many patient and home health agency characteristics that may affect our findings, which we did not adjust for in our analyses. Second, our sample of patients are limited to those who receive any home health within the 3 months following the month of cancer diagnosis. A prior analysis of postacute care use among SEER-Medicare cancer patients demonstrated that use of home health care was greatest in the first 100 days following surgery (3). However, not all of the patients in our analysis had cancer-directed surgery and not all home health use during this time period may have been directly related to the cancer diagnosis. Third, our findings do not account for differences in the period of exposure to home health after diagnosis. However, we did create rates adjusted for person months alive and enrolled in TM or MA and did not observe any differences from the raw percentages. For ease of presentation, we opted to display the raw, unadjusted percentages. Relatedly, some of the patients in our analysis received hospice care within 3 months of diagnosis, which may affect the receipt of home health services. However, we found that excluding hospice patients from our analysis did not have an impact on our results; thus, we did not exclude this population. There are also elements of our study design that relate to generalizability to the broader population of cancer patients. The SEER registries are population based; therefore, these findings reflect the characteristics of Medicare patients living in the SEER geographic areas. A prior study has reported that SEER-Medicare patients are representative of the US older population in terms of age, race, and sex, although these patients are less likely to live in rural areas than Medicare patients throughout the United States (23). In addition, our work is not generalizable to noncancer home health patients. It is possible that differences in MA and TM observed among this population of cancer patients may not be observed among beneficiaries with a different chronic disease. Finally, the SEER markets vary in their rates of MA penetration, as reflected in the distribution of MA and TM SEER-Medicare beneficiaries across these markets. This variation likely affects home health practice patterns across markets, as observed in prior studies (7). In conclusion, our study demonstrates the value of a new resource to understand the role of home health in the treatment and experience of older patients with cancer. Our research suggests that MA beneficiaries with cancer who use home health services have better cognitive and functional status than their TM counterparts, have lower rates of home health care utilization, and receive services for shorter amounts of time. More research is needed to understand why these differences exist and if they are associated with differences in outcomes. As MA continues to gain a larger share of the Medicare population, work is needed to better understand the experiences of care for specific subgroups of beneficiaries, including those with cancer. The newly created SEER-Medicare-OASIS database will be a valuable resource to address this and other questions related to home health care for cancer patients. These data can be accessed for SEER cancer patients on the SEER-Medicare website at https://healthcaredelivery.cancer.gov/seermedicare/. Notes Affiliations of authors: Center of Innovation in Long-Term Services and Supports, U.S. Department of Veterans Affairs Medical Center, Providence, RI, USA (KST); Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA (KST, MLS); Information Management Services, Inc, Calverton, MD, USA (EB, MJB); National Cancer Institute, Bethesda, MD, USA (DPW, ABM, JLW). The authors declare no conflicts of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, the National Cancer Institute, or the United States government. References 1 Medicare Payment Advisory Commission. 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JNCI MonographsOxford University Press

Published: May 1, 2020

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