To further understand documented associations between obesity and urban sprawl, this research describes individuals' trade-offs between health-related activities and commuting time. A cross-section of 24,861 working-age individuals employed full-time and residing in urban counties is constructed from the American Time Use Survey (2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010). Data are analyzed using seemingly unrelated regressions to quantify health-related activity decreases in response to additional time spent commuting. Outcomes are total daily minutes spent in physical activity at a moderate or greater intensity, preparing food, eating meals with family, and sleeping. Commuting time is measured as all travel time between home and work and vice versa. The mean commuting time is 62 min daily, the median is 55 min, and 10.1% of workers commute 120 min or more. Spending an additional 60 min daily commuting above average is associated with a 6% decrease in aggregate healthrelated activities and spending an additional 120 min is associated with a 12% decrease. The greatest percentage of commuting time comes from sleeping time reductions (28-35%). Additionally, larger proportions of commuting time are taken from physical activity and food preparation relative to the mean commuting length: of 60 min spent commuting, 16.1% is taken from physical activity and 4.1% is taken from food preparation; of 120 min commuting, 20.3% is taken from physical activity and 5.6% is taken from food preparation. The results indicate that longer commutes are associated with behavioral patterns which over time may contribute to obesity and other poor health outcomes. These findings will assist both urban planners and researchers wishing to understand time constraints' impacts on health.

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Key PointsQuestionWas the Centers for Medicare & Medicaid Services Oncology Care Model (OCM), an alternative payment model for cancer patients undergoing chemotherapy, associated with differences in Medicare spending, utilization, quality, and patient experience over the model’s first 3 years?FindingsIn this exploratory difference-in-differences study of Medicare fee-for-service beneficiaries with cancer undergoing chemotherapy (483 310 beneficiaries with 987 332 episodes treated at 201 OCM participating practices and 557 354 beneficiaries with 1 122 597 episodes treated at 534 comparison practices), OCM was associated with a statistically significant relative decrease in total episode payments of $297 that was not sufficient to cover the costs of care coordination or performance-based payments. There were no statistically significant differences in most measures of utilization, quality, or patient experiences.MeaningIn its first 3 years, the OCM was significantly associated with modestly lower Medicare episode payments that did not offset model payments to participating practices, and there were no significant differences in most utilization, quality, or patient experience outcomes.

Background Post-acute care (PAC) rehabilitation aims to maximize independence and facilitate a safe community transition. Yet little is known about PAC patients’ success in staying home post-discharge or differences on this outcome across PAC providers. Objectives Examine the percentage of PAC patients who remain in the community at least 30 days after discharge (i.e., successful community discharge) following hip fracture rehabilitation and describe differences among PAC facilities based on this outcome. Research Design Retrospective observational study. Subjects Community-dwelling, Medicare fee-for-service beneficiaries 75 years of age and older who experienced their first hip fracture between 1999–2007 (n=880,779). PAC facilities admitting hip fracture patients in 2006. Measures Successful community discharge, sites of readmission after PAC discharge. Results Between 1999 and 2007, 57% of patients achieved successful community discharge. Black were less likely (adjusted odds ratios=0.84, 95% confidence interval 0.82–0.86) than similar whites to achieve successful community discharge. Among all who re-entered the community (n=581,095), 14% remained in the community fewer than 30 days. Acute hospitals (67.5%) and institutional PAC (16.8%) were the most common sites of re-entry. The median proportion of successful community discharge among facilities was 49% (IQR: 33%–66%). Lowest-quartile facilities admitted older (85.9 vs. 84.1 years of age), sicker patients (e.g., higher rates of hospital complications 6.0% vs. 4.6%), but admitted fewer annually (7.1 vs. 19.3), compared to the highest quartile. Conclusions Re-entry into the healthcare system after PAC community discharge is common. Due to the distinct care needs of the PAC population there is a need for a quality measure that complements the current 30-day hospital readmission outcome and captures the objectives of PAC rehabilitation.

OBJECTIVES To examine the effect of the relationship between volume (number of hip fracture admissions during the 12 months before participant’s fracture) and other facility characteristics on outcomes. DESIGN Prospective observational study. SETTING U.S. skilled nursing facilities (SNFs) admitting individuals discharged from the hospital after treatment for hip fracture between 2000 and 2007 (N = 15,439). PARTICIPANTS Community-dwelling fee-for-service Medicare beneficiaries aged 75 and older admitted to U.S. hospitals for their first hip fracture and discharged to a SNF for postacute care from 2000 to 2007 (N = 512,967). MEASUREMENTS Successful discharge from SNF to community, defined as returning to the community within 30 days of hospital discharge to the SNF and remaining in the community without being institutionalized for at least 30 days, was examined using Medicare administrative data, propensity score matching, and instrumental variables. RESULTS The overall rate of successful discharge to the community was 31%. Of the 15,439 facilities, the facility interquartile range varied from 0% (25th percentile) to 42% (75th percentile). An important determinant of variation in discharge rate was SNF volume of hip fracture admissions. Unadjusted successful discharge from SNF to community was 43.7% in high-volume facilities (>24 admissions/year), versus 18.8% in low-volume facilities (1–6 admissions/year). This facility volume effect persisted after adjusting for participant and facility characteristics associated with outcomes (e.g., adjusted odds ratio = 2.06, 95% confidence interval = 1.91–2.21 for volume of 25 vs 3 admissions per year). CONCLUSION In community-dwelling persons with their first hip fracture, successful return to the community varies substantially according to SNF provider volume and staffing characteristics.

This was the first study to utilize time diary data to explore the relationship between commuting length and time spent with others. These estimates will inform researchers interested in time usages' impacts on physical and mental health.

During production of this paper, an incompletely corrected manuscript was mistakenly approved for publication at the proof stage. As a result, the originally published version of this article contained many small errors in the list shown below. None of these errors affect the conclusions of the paper; they have been corrected online. Cell Press apologizes for the errors and any inconvenience that may have resulted.

IMPORTANCE In the final days of life, symptoms are exacerbated and often families need both education and emotional support from hospice professional staff. The Medicare Hospice Benefit provides a per-diem payment with no requirements on the frequency of patient visits. OBJECTIVE To examine individual characteristics, hospice program, and geographic variation in hospice visits by professional staff during the last 2 days of life. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of 661 557 Medicare hospice beneficiaries included all patients who died in federal fiscal year 2014 (October 1, 2013-September 30, 2014) in hospice services while receiving routine home care in the last 2 days of life. Data analysis was conducted from March 9 to August 25, 2015. MAIN OUTCOMES AND MEASURES Medicare regulations require that hospice care centers report daily the frequency and duration of patient visits by professional staff, as well as the type of hospice staff who conduct these visits. We examined visit variation by hospice professional staff (physician, nursing staff, and social worker) during the last 2 days of life using a multivariable logistic model adjusting for decedent and hospice program characteristics. RESULTS Of the 661 557 patients in the study, 81 478 (12.3%) received no professional staff visits in the last 2 days of life. State variation ranged from 590 of 15 399 patients (3.8%) in Wisconsin to 97 of 492 patients (19.7%) in Alaska, and hospice program interquartile variation ranged from 3.2% (25th percentile) to 19.5% (75th percentile). Black patients were less likely to have any visits than were white patients (7352 of 48 221 [15.2%] vs 70 365 of 585 377 [12.0%]; adjusted odds ratio, 1.30; 95% CI, 1.24-1.37). Those dying in a nursing home were 1.74 times less likely to have any visits than those dying at home (30 880 of 186 649 [16.5%] vs 40 973 of 386 654 [10.6%]; 95% CI, 1.62-1.88). Those dying on a Sunday were 3.35 times less likely to have a visit compared with persons dying on a Tuesday (19 519 of 95 979 [20.3%] vs 6784 of 92 127 [7.4%]; 95% CI, 3.17-3.55). CONCLUSIONS AND RELEVANCE Hospice visits in the last 2 days of life by professional staff vary by race, hospice program, and geographic region of the country. Visits were less likely when the Medicare beneficiary was black, dying on a Sunday, and receiving care in a nursing home.