Validity of Race and Ethnicity Codes in Medicare Administrative Data Compared With Gold-standard Self-reported Race Collected During Routine Home Health Care Visits

Payment Source Shift for Surgical Care Among Veterans Enrolled in Medicare Advantage Plans

Importance

There is growing concern that Medicare Advantage (MA) plans are shifting the costs of care to the Veterans Health Administration (VHA) for veterans dually enrolled in both systems, particularly in high-veteran MA plans that disproportionately enroll veterans. However, empirical evidence evaluating the sources of payment for veterans' surgical care is lacking.

Objective

To evaluate differences in payment sources for surgical care between high-veteran MA plans and other MA plans.

Design, Setting, and Participants

This cross-sectional study used 2021 US national MA and VHA data from veterans dually enrolled in MA and VHA care for inpatient surgical episodes at VHA facilities (VHA-paid direct care), non-VHA community hospitals paid by VHA (VHA-paid community care), and community hospitals paid by MA (MA-paid community care) among veterans dually enrolled in MA and VHA care. Data were analyzed from April 1, 2024, to November 30, 2024.

Exposure

Enrollment in high-veteran MA plans.

Main Outcomes and Measures

Likelihood of utilizing VHA-direct care, VHA-paid community care, and MA-paid community care. High-veteran MA plans were defined as plans with 20% or more veteran enrollees; others were categorized as other MA plans. Multinomial logistic regression was used to evaluate the association of veteran enrollment in high-veteran MA plans with the likelihood of surgical care paid by each payment source, adjusting for veteran and surgery characteristics, and state fixed effects. Stratified analyses were conducted based on surgical complexity and source of admission.

Results

A total of 54 754 inpatient surgical episodes were analyzed, including 53 036 male (96.9%); 3133 Hispanic (5.7%), 47344 non-Hispanic Black (13.4%), 2933 non-Hispanic White (78.4%), and 1354 other or unknown race and ethnicity (2.5%); 601 (1.1%) were younger than 55 years, 3301(6.0%) aged 55 to 64 years, 22 381 (40.9%) aged 65 to 74 years, and 28471 (52%) aged 75 or older. Among these episodes, 52.1% were through MA-paid community care, 18.8% through VHA-direct care, and 29.1% through VHA-paid community care. Veteran enrollees in high-veteran MA plans were significantly less likely to have MA-paid surgeries (adjusted difference, -25.7 percentage points; 95% CI, -26.7 to 24.6 percentage points) and more likely to have surgeries paid through VHA-direct care (adjusted difference, 11.0 percentage points; 95% CI, 10.0-12.0 percentage points) and VHA-paid community care (adjusted difference, 14.7 percentage points; 95% CI, 13.6-15.8 percentage points) compared with veterans in other MA plans. As surgical complexity increased, differences in the use of VHA-paid direct care narrowed between high-veteran MA and other MA plans. Payment source differences were also less pronounced for nonelective surgeries admitted through emergency departments.

Conclusions and Relevance

The findings of this cross-sectional study suggest substantial cost shifting in veterans' surgical care from MA to VHA among high-veteran MA plans, underscoring the urgent need for policy reforms to improve the efficiency of veterans' care.

Risk of Adverse Pregnancy Outcomes Among Asian Individuals With Gestational Diabetes Mellitus in the U.S., 2016-2021

OBJECTIVE

The risk of adverse pregnancy outcomes (APOs) differs among race and ethnic groups with gestational diabetes mellitus (GDM). Heterogeneity in APOs may be masked by aggregating these groups. We assessed whether the frequency and risk of APOs differed among Asian groups with GDM.

RESEARCH DESIGN AND METHODS

This is a serial cross-sectional analysis of U.S. birth certificate data (2016-2021) from individuals with a singleton first livebirth. The exposure was self-reported maternal race and ethnicity stratified by Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese versus non-Hispanic White as the reference. Maternal outcomes included: primary cesarean delivery, hypertensive disorders of pregnancy (HDP), intensive care unit admission, and transfusion. Neonatal outcomes included large-for-gestational-age (LGA), small-for-gestational-age (SGA), preterm birth, and neonatal intensive care unit (NICU) admission.

RESULTS

The study population included 29,370 Indian, 16,146 Chinese, 9,082 Filipino, 6,497 Vietnamese, 3,754 Korean, and 1,253 Japanese individuals, and 254,433 White individuals. Between 2016 and 2021, the frequency of HDP, but not other APOs, increased among most Asian groups. In multivariable analyses, individuals in all Asian groups had higher likelihood of SGA and lower likelihood of LGA compared with White individuals. Findings for other APOs were heterogeneous. The risk of APOs was generally highest among Filipino individuals, followed by Indian individuals, and lowest among Chinese individuals among Asian groups.

CONCLUSIONS

There was significant heterogeneity in the frequency and risk of APOs among Asian individuals with GDM in the U.S. Disaggregation of the Asian population in diabetes and pregnancy research and surveillance is necessary to identify opportunities for intervention.

The contemporary natural history of minor amputation among diabetic patients with peripheral arterial disease

OBJECTIVES

The growing prevalence of diabetes and concomitant peripheral arterial disease (DM/PAD) has led to an increase in patients at risk for adverse limb events in current practice. Despite a widespread perception that minor amputation may result in both limb salvage and preserved functionality, the natural history of minor amputations remains unknown. Thus, we sought to quantify the rates of subsequent major amputation and survival among DM/PAD patients with any prior minor amputation.

METHODS

We performed a retrospective cohort study using US Medicare claims from 2007 to 2019. We included patients with DM/PAD based on International Classification of Diseases, 9th and 10th editions, diagnosis codes. We excluded patients lacking continuous fee-for-service coverage or with incomplete demographic data. The primary exposure was prior minor (below-ankle) amputation. The primary outcome was major (above-ankle) amputation. Statistical analyses were performed using the Kaplan-Meier method and Cox proportional hazards modeling.

RESULTS

We identified 12,257,174 patients (age 73 ± 11 years; 48% male; 76% White) with DM/PAD. Of these patients, 2.2% (n = 274,225) underwent prior minor amputation. Patients with prior minor amputation were more likely to be male (63% vs 47%; P < .0001), Black non-Hispanic (17% vs 13%; P < .0001), and rural (25% vs 21%; P < .0001) than those without prior minor amputation. The 5-year Kaplan-Meier cumulative incidence of major amputation was 27% (n = 58,613) of patients with prior minor amputation, compared with 1.4% (n = 129,872) of patients without prior minor amputation. After risk-adjustment, patients with prior minor amputations were 6.1-fold more likely to require a subsequent major amputation (hazard ratio, 6.11; 95% confidence interval, 6.04-6.18) compared with those without prior minor amputations.

CONCLUSIONS

This contemporary claims-based analysis demonstrates that approximately 25% of Medicare beneficiaries with DM/PAD and prior minor amputation will necessitate a major amputation within 5 years. Prior minor amputation carries a risk of major amputation comparable with de novo tissue loss and is a stronger predictor than any demographic or socioeconomic exposure. These results help to inform both clinical decision-making and anticipated real-world outcomes among those at greatest risk for limb loss.

Socioeconomic Status Mediates and Modifies Racial and Ethnic Disparities in Incisional Glaucoma Surgical Outcomes

PURPOSE

To estimate the proportion of racial and ethnic disparities observed in glaucoma surgical outcomes that can be eliminated by curbing differences in socioeconomic status (SES).

DESIGN

Retrospective cohort study.

SUBJECTS

The entire population of 2016-2018 California (CA) fee-for-service Medicare beneficiaries with a claim for incisional glaucoma surgery (trabeculectomy, tube shunt, or EX-PRESS shunt).

METHODS

The primary exposure was race and ethnicity, stratified into: Non-Latinx White (as the reference category), Black, Latinx, Asian/Pacific Islander (PI), and Other. The SES mediator was dichotomized to low vs. nonlow based on dual-eligibility for Medicaid. Outcome (time to failure event) was defined as having a claim for a glaucoma surgery revision or reoperation event.

MAIN OUTCOME MEASURES

The total effect (TE) estimated the entire racial and ethnic disparity. The controlled direct effect (CDE) estimated the remaining disparity after fixing SES to nonlow for all, and the proportion eliminated (PE) estimated the proportion of the disparity eliminated after uniform SES assignment. The TE and CDE estimates are interpreted as hazards ratios given time-to-event modeling using Cox proportional hazards.

RESULTS

The final analytical sample included a total of 5985 unique CA beneficiaries. After uniformly fixing SES to nonlow, the racial and ethnic disparity for Black patients dissipated most (TE: 1.18, 95% CI: 0.99-1.41; CDE: 1.01, 95% CI: 0.80-1.77), followed by Latinx patients (TE: 1.23, 95% CI: 1.08-1.51; CDE: 1.10, 95% CI: 0.90-1.35), Other race and ethnicity patients (TE: 1.32, 95% CI: 1.03-1.70; CDE: 1.24, 95% CI: 0.91-1.68), and Asian/PI patients (TE: 1.18, 95% CI: 1.02-1.36; CDE: 1.21, 95% CI: 0.99-1.47). The PE estimates suggest that equalizing SES would eliminate varying levels of disparities, with a maximum of 96% for Black patients (PE: 0.96, 95% CI: -0.27 to 2.19), followed by 54% for Latinx patients (PE: 0.54, 95% CI: -0.25 to 1.33), and no significant change for Other race and ethnicity (PE: 0.24, 95% CI: -0.49 to 0.97), and Asian/PI patients (PE: -0.18, 95% CI: -1.11 to 0.75).

CONCLUSIONS

We found that SES mediates racial and ethnic disparities in glaucoma surgical outcomes, though by varying amounts by individual racial and ethnic group. Of note, addressing SES differences would eliminate 96% of the disparity for Black beneficiaries.

Racial and Ethnic Disparities in Receipt of ERBB2-Targeted Therapy for Breast Cancer, 2010-2020

Importance

Among older women (aged ≥50 years) with ERBB2 (formerly HER2 or HER2/neu)-positive breast cancer, research has shown racial and ethnic disparities in access to ERBB2-targeted therapies, with Black women receiving treatment at lower rates than their White counterparts.

Objective

To examine racial and ethnic disparities in receipt of ERBB2-targeted therapies and changes in receipt over time.

Design, Setting, and Participants

This retrospective cohort study used Surveillance, Epidemiology, and End Results-Medicare linked data from January 1, 2010, to December 31, 2020. Beneficiaries who were diagnosed with ERBB2-positive breast cancer between 2010 and 2019, were aged 66 years or older at diagnosis, were continuously enrolled in Medicare Parts A and B in the 12 months before and after diagnosis, and had localized or regional stage disease at diagnosis were included. Data were analyzed from February through September 2024.

Exposure

Race and ethnicity defined as non-Hispanic Black or African American, Hispanic, or non-Hispanic White.

Main Outcome and Measures

The primary outcome was receipt of ERBB2-targeted therapies in the 12 months after diagnosis of ERBB2-positive breast cancer. Modified Poisson regression was used to evaluate the probability of receiving ERBB2-targeted therapy by race and ethnicity.

Results

Among 12 765 beneficiaries with ERBB2-positive breast cancer (median [IQR] age, 74 [69-80] years; 99.2% female), 8.1% were of Black, 6.9% Hispanic, and 85.0% White race and ethnicity, and 54.2% received ERBB2-targeted therapy. The overall proportion who received ERBB2-targeted therapies increased from 41.3% in 2010-2011 to 64.3% in 2018-2019. Compared with White patients, Black patients had a lower likelihood of receiving ERBB2-targeted therapies in 2010-2011 (adjusted risk ratio [ARR], 0.81; 95% confidence limit [CL], 0.68-0.97), as did Hispanic patients (ARR, 0.75; 95% CL, 0.62-0.92). Racial and ethnic disparities in receipt of ERBB2-targeted therapies narrowed over time, with no significant differences observed across racial and ethnic groups in 2018-2019 for Black patients (ARR, 0.97; 95% CL, 0.87-1.08) and Hispanic patients (ARR, 1.05; 95% CL, 0.95-1.16).

Conclusions and Relevance

These findings suggest a narrowing of racial and ethnic disparities in receipt of ERBB2-targeted therapies over time among older Medicare beneficiaries with ERBB2-positive breast cancer. Future research is needed to understand the practices that contributed to the narrowing of racial and ethnic disparities and to develop implementation strategies to effectively improve the quality and equity of breast cancer care.

Long-Term Spending of Accountable Care Organizations in the Medicare Shared Savings Program

Importance

Evidence from initial cohorts of accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP) found modest reductions in health care spending. Little is known about whether these effects have changed over time.

Objective

To determine long-term changes in spending for MSSP ACO participants.

Design, Setting, and Participants

Using 2010 to 2019 traditional Medicare data, difference-in-differences analyses were performed to compare spending changes for patients attributed to ACOs relative to changes for patients at non-ACO organizations. Outcomes included total Medicare spending and spending by category. Three- and 6-year effects and estimated differential changes overall and by ACO characteristics were calculated, including size (small defined as <10 000 patients), rurality, and whether an ACO included a hospital (hospital-associated ACO) or not (physician-group ACO).

Exposure

Attribution to a medical group or clinic in an ACO during the first 2 years of ACO tenure.

Main Outcomes and Measures

Total annual per-patient Medicare spending.

Results

The sample included 41 973 272 Medicare patient-years. Baseline characteristics for 2 719 406 ACO patients and 5 523 652 control patients were similar (average age, 72 years; 58% female; and 82% to 84% White) prior to ACO formation in 2010 and 2011, and unadjusted annual per-patient spending was slightly lower in the ACO group vs control group ($12 147 vs $12 318; difference, -$171 [95% CI, -$223 to -$118]) in the 2 years prior to ACO formation. ACO formation was associated with a mean differential reduction of $142 (95% CI, -$193 to -$92) in annual per-patient spending over 3 years and $294 (95% CI, -$347 to -$241) over 6 years. Spending reductions associated with ACO formation increased over time: compared with control patients, ACO patients experienced a mean reduction of $234 (95% CI, -$298 to -$171) in year 3 and $584 (95% CI, -$680 to -$489) in year 6. Physician-group and small ACOs generated larger spending reductions. Spending changes resulted in $4.1 billion to $8.1 billion in savings to Medicare between 2012 and 2019.

Conclusions and Relevance

During the MSSP's first decade, ACOs generated meaningful reductions in spending, with larger effects over time.

Associations Between Measures of Structural Racism and Acute Ischemic Stroke Incidence in the United States

BACKGROUND AND OBJECTIVES

Racial differences in socioeconomic characteristics are believed to be secondary to structural racism. While socioeconomic factors explain some of the racial disparity in stroke incidence at an individual level, little is known about the association between societal-level structural racism and incidence of acute ischemic stroke (AIS). We aimed to determine whether the geographic racial disparity in stroke incidence across the United States is associated with structural racism.

METHODS

We performed a national, population-based analysis of 71,078,619 adults (844,406 with incident AIS) aged 65 years and older who were enrolled in Medicare from January 1, 2016, to December 31, 2019. The primary exposure was a composite score calculated from 8 county-level measures of structural racism (segregation indices [delta, dissimilarity, isolation], Gini index, housing discrimination, educational attainment, employment, and income) that account for validated domains of structural racism based on an ecosocial model. The primary outcome was incident AIS. Marginal Cox models with data clustered at the county level were used to estimate the hazard ratio (HR) of AIS incidence, comparing Black individuals with White individuals. Separate marginal Cox models tested associations between each measure of structural racism and AIS incidence, with further testing to screen for interaction with the race variable.

RESULTS

The composite structural racism score identified significant geographic variation in structural racism across the United States (mean 0.818, SD 2.874, interquartile range 3.02). Black individuals had a 19% increased hazard of AIS compared with White individuals (HR 1.19, 95% CI 1.14-1.25, p < 0.0001). All constituent measures of structural racism, except for housing discrimination, were associated with AIS incidence independently of race. Each SD increase in the composite structural racism score was associated with an 18% increased incidence in AIS in the total population. This association interacted with race (p = 0.03), with a greater magnitude of association for White (HR 1.19, 95% CI 1.13-1.25, p < 0.0001) vs Black (HR 1.09, 95% CI 1.03-1.16, p = 0.0073) individuals.

DISCUSSION

There is significant county-level geographic variation in structural racism across the United States, and increasing levels of structural racism are associated with increased incidence of AIS, regardless of race.

Influence of Medicaid Expansion on Rural Medicare Beneficiaries Undergoing Colon Cancer-Directed Surgery in the United States

BACKGROUND

The 2010 Affordable Care Act increased access to colon cancer care for millions of non-elderly adults; however, the direct and indirect impact of Medicaid expansion on Medicare beneficiaries with cancer remains less clear, especially for elderly beneficiaries in rural communities.

METHODS

Medicare Provider Analysis and Review file was queried for all fee-for-service (FFS) beneficiaries undergoing cancer-directed surgery for colon cancer between 2012 and 2019. Our primary outcomes included 90-day postoperative morbidity, mortality, return to an emergency department, or readmission in the form of an inpatient hospitalization. Multivariable hierarchical logistic regression analyses akin to a difference-in-difference model were performed, allowing the intervention units (US states) to undergo expansion at different times while also controlling for demographic, clinical, and residential geospatial characteristics. Secondary analyses examined for an interaction between rurality and expansion.

RESULTS

Final analysis included 221,814 Medicare beneficiaries who underwent colon cancer-directed surgery between 2012 and 2019. Overall, 141,159 (63.6%) beneficiaries resided in states that adopted expanded Medicaid eligibility. Controlling for confounding factors, Medicaid expansion was not associated with postoperative surgical outcomes, including 90-day morbidity (p = 0.56), mortality (p = 0.30), presentation to an emergency department (p = 0.79), or readmission to an inpatient hospital (p = 0.43). Similarly, analyses evaluating differential association of expansion on rural beneficiaries found no significant differences associated with Medicaid expansion for rural compared with metropolitan beneficiaries.

CONCLUSIONS

In these analyses of over 200,000 Medicare beneficiaries across the United States, we found that Medicaid expansion was not associated with any changes in postoperative outcomes for Medicare beneficiaries undergoing colon cancer-directed surgery, either overall or by rural place of residence.

Frailty Is Strongest Need Factor Among Predictors of Prehabilitation Utilization for Total Hip or Knee Arthroplasty in Fee-for-Service Medicare Beneficiaries

OBJECTIVE

Prehabilitation may have benefits for total hip arthroplasty (THA) and total knee arthroplasty (TKA), given an aging population with multimorbidity and the growth of value-based programs that focus on reducing postoperative costs. This study aimed to describe prehabilitation use and examine predictors of utilization in fee-for-service Medicare beneficiaries.

METHODS

This retrospective cohort study using the Medicare Limited Data Set included fee-for-service Medicare beneficiaries who were ≥66 years old and who underwent inpatient elective THA or TKA between January 1, 2016, and September 30, 2021. The study assessed predictors of receiving preoperative physical therapist services within 90 days of surgery (prehabilitation) using a mixed-effects generalized linear model with a binary distribution and logit link. Adjusted odds ratios (ORs) were reported.

RESULTS

Of 24,602 THA episodes, 18.5% of patients received prehabilitation; of 38,751 TKA episodes, 17.8% of patients received prehabilitation. For both THA and TKA, patients with medium or high (vs low) frailty were more likely to receive prehabilitation (OR = 1.72-2.64). Male (vs female) patients, Black (vs White) patients, those with worse county-level social deprivation, those with dual eligibility, and those living in rural areas were less likely to receive prehabilitation before THA or TKA (OR = 0.65-0.88). Patients who were ≥85 years old (vs 66-69 years old) and who underwent THA were also less likely to receive services (OR = 0.84). Additionally, there were geographic differences in prehabilitation utilization and increased utilization in more recent years.

CONCLUSION

The need factor of frailty was most strongly associated with increased prehabilitation utilization. The variation in utilization by predisposing factors (eg, race) and enabling factors (eg, county-level social deprivation) suggests potential disparities.

IMPACT

The findings describe prehabilitation use in a large cohort of fee-for-service Medicare beneficiaries. Although services seem to be targeted to those at greater risk for adverse outcomes and high spending, potential disparities related to access warrant further examination.

Understanding the Effect of Race on Medicare Advantage Enrollment

OBJECTIVE

To understand why Medicare Advantage (MA) has a relatively larger market share among racial minorities than traditional Medicare (TM).

STUDY SETTING AND DESIGN

We estimate Probit models for the choice of the MA sector versus TM by Black and Hispanic beneficiaries, as compared with White beneficiaries. We use a non-linear version of the Oaxaca-Blinder decomposition to decompose differences in the probability of MA enrollment by race into differences in explanatory variable values versus differences in the coefficients on those variables, which we identify as "preferences" for MA.

DATA SOURCES AND ANALYTIC SAMPLE

We combined 2020 Medicare Current Beneficiary Survey (MCBS) data with CMS data on MA plan payment levels aggregated to the county level, star ratings, and measures of market competition.

PRINCIPAL FINDINGS

In the Black/White beneficiary comparison, 83% of the 17% point difference in the probability of MA enrollment was explained by differences in preferences (p < 0.001) while only 17% was explained by differences in attributes (p < 0.05). In contrast, in the Hispanic/White beneficiary comparison, 72% of the difference was explained by differences in attributes (p < 0.001) and 28% was explained by differences in preferences (p < 0.01). Attributes associated with differing rates of MA enrollment by race included both market-level characteristics (e.g., payment levels) and personal characteristics (age, level of pain, and chronic disease count). Preferences associated with differing rates of MA enrollment included coefficients of sector characteristics such as payment rates and the number of four-star+ plans available and age.

CONCLUSIONS

In this study, we find that the higher MA enrollment rate for Black versus White beneficiaries is largely associated with differences in preferences, while the higher enrollment rate for Hispanic beneficiaries is more associated with differences in attributes. Differences in preferences for MA sector characteristics were significant in explaining higher MA enrollment rates for both groups compared with White beneficiaries, suggesting that changes in payment rates will disproportionately impact racial minorities, particularly for Black beneficiaries. However, the reasons for different preferences for MA among racial groups remain somewhat of a puzzle, particularly given that we control for demographics, health, and market characteristics.

Should I stay or should I go again: Multiple switching between fee-for-service Medicare and Medicare advantage among older beneficiaries

OBJECTIVE

To evaluate whether having previously disenrolled from Medicare Advantage (MA) is associated with lower hazards of future MA enrollment.

DATA SOURCES AND STUDY SETTING

Secondary data from Medicare.

STUDY DESIGN

We examined beneficiaries with baseline FFS enrollment from 2017-2019 using a 20% sample of Medicare claims. Cox proportional hazard models were used to examine the association of prior MA enrollment (in the three years prior to baseline FFS enrollment) with MA re-enrollment, and whether this association is modified by Alzheimer's Disease and Related Dementias (ADRD), prior nursing home use, chronic illness, dual eligible status, and availability of MA plans and quality.

DATA COLLECTION

Not applicable.

PRINCIPAL FINDINGS

Overall, 3.3% of beneficiaries switched to MA annually. Of those with prior MA enrollment, MA switching percentages were 9.0%, 4.6%, and 6.8% for those whose most recent MA enrollments were 1, 2, and 3 years prior to their baseline FFS year. Comparatively, the switching percentages was 3.2% for those with no prior MA enrollment. The hazards of switching to MA were 2.73 (p < 0.001), 1.29 (p < 0.001), and 1.97 (p < 0.001) times greater than remaining in FFS for beneficiaries whose most recent MA enrollments were one, two, and three years prior to their baseline FFS year. Hazards of switching were generally similar between those with and without ADRD, stratified by recency in prior MA experience, except those with dual eligibility. Among those with ADRD, switching hazards were greatest for 3 years prior MA enrollees in counties with the fewest available (HR: 3.84, p < 0.001) and lowest-rated plans (HR: 4.02, p < 0.001).

CONCLUSIONS

Recency of switching from MA to FFS was the strongest predictor of a FFS-to-MA switch, identifying a population of beneficiaries who multiply switch regardless of health status or MA access. Future health policy considerations should more closely examine the vulnerabilities and long-term outcomes of this population.

Associations Between Measures of Structural Racism and Receipt of Acute Ischemic Stroke Interventions in the United States

BACKGROUND

Structural racism and rural/urban differences in stroke care affect care delivery and outcomes. We explored the interplay among structural racism, urbanity, and intravenous thrombolysis (tissue plasminogen activator) and endovascular thrombectomy (ET).

METHODS AND RESULTS

In this retrospective study using complete, deidentified inpatient Medicare data (2016-2019), we identified incident acute ischemic stroke admissions, demographics, and hospital-level variables. Medicare beneficiaries aged ≥65 years with incident acute ischemic stroke admission in large metropolitan and nonurban settings were included. Validated structural racism metrics at the county level and a composite structural racism score that incorporated measures of segregation, housing, employment, education, and income were studied. Among 951 914 patients, rural hospitals demonstrated lower intensive care unit capacity (27.5% versus 88.6%), stroke certification (5.3% versus 38.4%), and rates of tissue plasminogen activator (1.6% versus 12.3%) and ET (<1% versus 3.8%). Large metropolitan areas demonstrated higher levels of income inequality (Gini index -0.15 versus 0.11 SD), and racial segregation (dissimilarity index 0.29 SD higher than the US mean). The composite structural racism score was associated with increased odds of tissue plasminogen activator receipt (odds ratio, 1.47 [95% CI, 1.33-1.63]) and ET (odds ratio, 4.15 [95% CI, 2.98-5.79]). Despite greater access to stroke care in urban areas, a persistent racial disparity remained, with Black patients less likely to receive tissue plasminogen activator (odds ratio, 0.70 [95% CI, 0.68-0.72]) and ET (odds ratio, 0.63 [95% CI, 0.60-0.66]) compared with White patients.

CONCLUSIONS

We found persistent disparities in stroke care access and outcomes, influenced by structural racism and rural-urban differences. Further research should explore interactions between structural racism, urbanity, and health care delivery to inform effective interventions.

Screening History, Stage at Diagnosis, and Mortality in Screen-Detected Breast Cancer

Importance

Screening mammography promotes early detection of breast cancer and is associated with reduced breast cancer mortality. Screening history prior to diagnosis may impact stage at diagnosis and breast cancer mortality but has not been comprehensively examined within a diverse US cohort.

Objective

To determine whether having a prior screening is associated with earlier stage at breast cancer diagnosis and lower breast cancer-specific mortality.

Design, Setting, and Participants

This cohort study used linked Surveillance, Epidemiology, and End Results-Medicare data of women aged at least 70 years, diagnosed with estrogen receptor-positive or human epidermal growth factor receptor 2-negative breast cancer from 2010 to 2017, and enrolled in fee-for-service Medicare Parts A and B from 5 years prior to through 1 year after diagnosis. Data were analyzed from March 1 to September 18, 2024.

Exposure

Presence of 1 or more screening mammograms during the 5 years prior to the mammogram at breast cancer diagnosis.

Main Outcomes and Measures

Outcomes of interest were stage of breast cancer at diagnosis, dichotomized into very early (T1N0) vs later stage (T2+ or N1+) and breast cancer-specific mortality.

Results

Among 13 028 included women, most had at least 1 prior screening (10 094 women [77.5%]) and were aged between 70 and 79 years (9034 women [69.4%]) and not dual-eligible for Medicare and Medicaid (11 475 women [88.1%]). Additionally, 3812 women (29.3%) were diagnosed with later-stage disease (T2+ or N1+) at the time of diagnosis. In multivariable analyses, prior screening was associated with 54% lower odds of later-stage breast cancer diagnosis (adjusted odds ratio, 0.46; 95% CI, 0.42-0.50) and 36% lower hazard of breast cancer-specific death (adjusted hazard ratio, 0.63; 95% CI, 0.52-0.76) compared with no prior screenin. In the adjusted Cox proportional hazards model, having 3 or 4 prior screenings was associated with 37% reduced hazard of breast cancer-specific mortality compared with having 1 prior screening (adjusted hazard ratio, 0.63; 95% CI, 0.44-0.89).

Conclusions and Relevance

In this cohort study of older women with screen-detected estrogen receptor-positive or human epidermal growth factor receptor 2-negative breast cancer, prior screening mammography was associated with earlier stage at breast cancer diagnosis and lower breast cancer mortality. These findings support the potential for routine screening to improve breast cancer outcomes. As with all observational studies, this study is limited by the potential effects of other differences between the screening and nonscreening groups.

Telemedicine Adoption and Low-Value Care Use and Spending Among Fee-for-Service Medicare Beneficiaries

Importance

Low-value care is a persistent problem with direct and cascading harms. Telemedicine is now commonly used and may reduce low-value testing by introducing barriers to completing tests at a given visit or expand opportunities for low-value testing by contributing to higher visit volumes.

Objective

To quantify the association between telemedicine adoption and low-value testing among fee-for-service Medicare beneficiaries.

Design, Setting, and Participants

In this cohort study using 100% fee-for-service Medicare claims data, US health systems were divided into quartiles based on 2020 telemedicine adoption. Beneficiary-level linear regression in difference-in-differences (DiD) analyses was used to compare beneficiaries who were continuously enrolled from 2019 through 2022 and were attributed before telemedicine adoption (2019) to high telemedicine-adopting (top quartile) vs low telemedicine-adopting (bottom quartile) health systems on low-value test and visit outcomes in 2022 vs 2019. Data were analyzed from October 2023 to December 2024.

Exposure

Health system telemedicine adoption.

Main Outcomes and Measures

Receipt of, and spending on, 20 low-value screening, preoperative, chronic condition management, and acute diagnostic tests, as well as total visits (in person and virtual).

Results

The sample included 1 382 033 beneficiaries who were attributed to high-telemedicine systems (mean [SD] age, 71.6 [10.5] years; 58.8% female) and 999 051 beneficiaries who were attributed to low-telemedicine systems (mean [SD] age, 71.8 [10.0] years; 57.0% female). From 2019 to 2022, those in high-telemedicine systems had a small differential rise in visits (DiD visits per beneficiary, 0.12; 95% CI, 0.03 to 0.21) and differential decreases in use of 7 of 20 low-value tests: cervical cancer screening (DiD, -0.45 percentage points [pp]; 95% CI, -0.72 to -0.17 pp), screening electrocardiograms (DiD, -1.30 pp; 95% CI, -1.96 to -0.65 pp), screening metabolic panels (DiD, -1.84 pp; 95% CI, -2.87 to -0.80 pp), preoperative complete blood cell counts (DiD, -0.64 pp; 95% CI, -1.06 to -0.22 pp), preoperative metabolic panels (DiD, -1.35 pp; -1.91 to -0.80 pp), total or free T3 (triiodothyronine) level testing for hypothyroidism (DiD, -0.90 pp; 95% CI, -1.38 to -0.41 pp), and imaging for uncomplicated low back pain (DiD, -1.66 pp; 95% CI, -2.35 to -0.98 pp). There were no statistically significant differences in other tests. Those in high-telemedicine systems saw statistically significant differential decreases in spending on visits per beneficiary (-$47.87; 95% CI, -$86.85 to -$8.88) and on 2 of 20 low-value tests, but no differences in low-value spending overall.

Conclusions and Relevance

In this cohort study, telemedicine adoption was associated with modestly lower use of 7 of 20 examined low-value tests (most point-of-care) and no changes in use of other low-value tests, despite a small rise in total visits that might offer more testing opportunities. Results suggest possible benefits of telemedicine and mitigate concerns about telemedicine contributing to increased spending.

Extreme Heat and Hospitalization Among Older Persons With Alzheimer Disease and Related Dementias

Importance

As US society ages and the climate changes, extreme outdoor heat may exacerbate the health burden of Alzheimer disease and related dementias (ADRD), but where, when, and among whom extreme heat may increase hospitalizations with ADRD remains understudied.

Objective

To investigate the association between extreme heat and the risk of hospitalization with ADRD, and to explore how associations differ across climates and population subgroups.

Design, Setting, and Participants

Population-based cohort study, using a time-stratified case-crossover design, of Medicare fee-for-service (Part A) claims from 2000 to 2018 among beneficiaries aged 65 years or older in the contiguous US; time-stratified case-crossover design implemented with distributed lag nonlinear models using conditional logistic regression. Data were analyzed from October to November 2024.

Exposures

Daily maximum heat index converted to percentiles of climate-specific warm season heat index distributions.

Main Outcomes and Measures

The main outcome was each beneficiary's first hospitalization with an ADRD diagnosis code, and other measures were county-level climates (arid, continental, temperate, or tropical).

Results

The sample included 3 329 977 beneficiaries (2 126 290 [63.9%] female, 33 887 [1.0%] Asian, 354 771 [10.7%] Black, 61 515 [1.8%] Hispanic, 2 831 391 [85.0%] White, and 891 815 [26.8%] dual eligible for Medicaid). The odds ratio (OR) of hospitalization with ADRD comparing days in the 99th vs 50th percentile of the heat index distribution was 1.02 (95% CI, 1.01-1.02), corresponding to 0.8 (95% CI, 0.5-1.1) additional hospitalizations with ADRD per 1000 beneficiaries. Results suggest extreme heat associations persist for 3 days beyond the initial day. The cumulative OR of hospitalization with ADRD after 4 days of continuous exposure to heat indexes at the 99th vs 50th percentile was 1.04 (95% CI, 1.03-1.04), or 1.7 (95% CI, 1.3-2.0) additional hospitalizations with ADRD per 1000 beneficiaries. Extrapolating these estimates to the 6.7 million adults currently living with ADRD suggests that each day of extreme heat could contribute to at least 5360 added hospitalizations with ADRD nationwide. Effects estimates were similar in temperate and continental climates. Arid and tropical climate estimates were somewhat similar but more uncertain. OR point estimates for hospitalization from 4 days of continuous extreme heat exposure for beneficiaries identifying as Asian (OR, 1.09; 95% CI, 1.02-1.17), Black (OR, 1.07; 95% CI, 1.05-1.10), and Hispanic (OR, 1.08; 95% CI, 1.03-1.13), were 2.6 to 3.2 times larger than for White beneficiaries (OR, 1.03; 95% CI, 1.02-1.04).

Conclusions and Relevance

This study found that extreme heat may pose a growing threat to older adults living with ADRD. This threat may be larger among Asian, Black, and Hispanic racial and ethnic groups. Clinicians should consider counseling patients living with ADRD on extreme heat risks, and policymakers should devise risk mitigation programs.

Multiethnic norms for blood pressure response to submaximal exercise testing in young-to-middle adulthood and associations with hypertension: The NHANES dataset

The blood pressure (BP) response during exercise testing is a robust correlate of hypertension in middle-to-older White people, but whether this extends to a healthy, young-to-middle-aged multiethnic population is unknown. Moreover, it is unclear what constitutes an exaggerated BP to submaximal exercise, which is a more reliable and stronger correlate of hypertension than maximal testing. The NHANES dataset was used to interrogate the association of submaximal exercise BP with current hypertension and to provide multiethnic norms for BP responses in young-to-middle-aged adults. The analyses combined NHANES cycles wherein treadmill exercise testing was conducted with an analytic sample of 2544 participants aged 12-49 years (Female: White = 467; Black = 324; Hispanic = 439; Male: White = 493, Black = 351; Hispanic = 470). Weighted logistic models were fitted to test associations between exercise BP and hypertension. Age, sex, and race-specific percentiles were estimated. Exaggerated systolic BP (SBP) responses to exercise testing were defined as readings ≥90th percentile, and ≥ROC-derived cutoff. Regardless of race, sex, exercise workload, clinical and socioeconomic characteristics, a 5-mmHg increase in SBP and diastolic BP during stage 1 of exercise testing was associated with a 15% (aOR: 1.15, 95% CI: 1.08-1.21), and 31% (aOR: 1.31, 95% CI: 1.22-1.40) higher odds for hypertension, respectively. Black males had the highest proportion of exaggerated SBP responses (44%, 95% CI: 36-53%) when defined only via ROC-derived cutoffs. BP responses during submaximal exercise were associated with hypertension, irrespective of race in young-to-middle adulthood. Still, the exaggerated SBP response to exercise of Black males suggests uncontrolled high BP not detected at rest.

Association of Race and Ethnicity With Healthcare Utilization for Inflammatory Bowel Disease in the United States: A Retrospective Cohort Study

INTRODUCTION

Advances in medical and surgical therapy have improved the outlook for those affected with Crohn's disease and ulcerative colitis; however, it is unclear whether Americans from marginalized racial and ethnic backgrounds have adequate and equitable access to care for inflammatory bowel disease (IBD). We evaluated the association between race and ethnicity and healthcare utilization in patients diagnosed with inflammatory bowel disease.

METHODS

This study identified children and adults diagnosed with IBD in 2 national data sets from 2016 to 2017. We modeled the association between healthcare utilization and racial and ethnic subpopulations across different age groups using generalized estimating equations adjusted by disease and socioeconomic factors.

RESULTS

Among working-age adults, Black Americans had higher emergency department admission, hospitalization, and steroid use than White patients; however, these differences were attenuated after adjusting for socioeconomic factors. Asian and Hispanic Americans were less likely to receive outpatient gastroenterological care and medical therapy even after adjustment. Emergency department use was more likely among elderly Black patients. Hispanic children had increased healthcare utilization for IBD compared with White children, although these results did not meet statistical significance.

DISCUSSION

Healthcare utilization for long-term management of IBD is lower in historically marginalized racial and ethnic groups compared with White Americans. Further research is needed to identify and address modifiable patient, clinician, and healthcare system barriers to achieve health equity in the management of IBD.

Segregation in hospital care for Medicare beneficiaries by race and ethnicity and dual-eligible status from 2013 to 2021

OBJECTIVE

To examine the extent of segregation between hospitals for Medicare beneficiaries by race, ethnicity, and dual-eligible status over time.

DATA SOURCES AND STUDY SETTING

We used Medicare inpatient hospital provider data for fee-for-service (FFS) beneficiaries, and the Dartmouth Atlas of Health Care from 2013 to 2021 nationwide, for hospital referral regions (HRRs), and for and hospital service areas (HSAs).

STUDY DESIGN

We conducted time trend analysis with dissimilarity indices (DIs) for Black (DI-Black), Hispanic (DI-Hispanic), non-White (including Black, Hispanic, and other non-White) (DI-non-White), and dual-eligible (DI-Dual) beneficiaries. DIs between hospitals were contextualized and correlated with population compositions and residential DIs.

DATA COLLECTION/EXTRACTION METHODS

We included 3177 hospitals with more than 250 Medicare FFS beneficiaries discharged per year. We cross-linked data on hospital-level patient race, ethnicity, and dual-eligible status with geographic data and examined time trends using linear mixed models.

PRINCIPAL FINDINGS

Nationwide DIs ranged from 0.23 to 0.53. HRRs and HSAs generally had low segregation (DI medians: 0.08-0.19, highest among Black, then non-White, Hispanic, and dual-eligible beneficiaries). However, some HRRs and HSAs had moderate or high segregation (DI-Black >0.30 in 19.1% of HRRs and 5.8% of HSAs; DI-non-White >0.30 for two HRRs with high American Indian/Alaska Native populations). Time trends indicated small declines in segregation from 2013 to 2021 (0.15%-0.30% per year; all p < 0.001). DI-Dual correlated moderately with non-White populations.

CONCLUSIONS

For Medicare FFS, we observe generally low and slightly declining levels of segregation across HRRs and HSAs, with notable exceptions. Improving race reporting and contextualizing select areas of higher segregation with their hospital and residential population compositions can help frame and understand health inequities. Interpretation of HRR-level DI may require additional historical, demographic, and spatial context due to its potential to oversimplify, overstate, or obscure segregation. Future work should identify drivers and mitigators of segregation, including sorting patterns among health systems.

Epilepsy in the Indigenous peoples in Canada, Australia, New Zealand, and the USA: a systematic scoping review

BACKGROUND

Indigenous peoples have inequitable health access and outcomes yet are under-represented in health research and policy. The Intersectoral Global Action Plan on Epilepsy and other Neurological Disorders 2022-2031 highlights Indigenous peoples as high priority groups. We aimed to provide a summary of existing knowledge regarding epilepsy among Indigenous peoples in Canada, Australia, New Zealand, and the USA (CANZUS).

METHODS

In this systematic scoping review, we searched Embase, MEDLINE, APA PsychInfo, Cochrane, Scopus, CINAHL databases and grey literature for reports published in any language between Jan 1, 1985, and April 16, 2023, using search terms related to seizures, epilepsy, and Indigenous peoples. Studies were assessed independently by three reviewers. Articles including epilepsy data in an Indigenous group were included. Articles were excluded if they combined Indigenous and non-Indigenous peoples as one population or if the outcomes did not include a separate analysis by Indigenous group. Case reports were also excluded. We extracted data on epilepsy epidemiology, access to health care, treatment, and health outcomes in Indigenous people. The methodological quality of studies was assessed through a methodological appraisal and an Indigenous perspective appraisal. This study is registered with Open Science Framework, https://doi.org/10.17605/OSF.IO/9JRHG.

FINDINGS

Our search identified 2037 studies, of which 42 peer-reviewed articles and nine grey literature reports met inclusion criteria: these studies were in Canada (n=3), Australia (n=17), New Zealand (n=9), and the USA (n=22). With the exception of Māori children in New Zealand, who seem to have similar rates of epilepsy to children of European ancestry, the incidence and prevalence of epilepsy seemed to be higher in Indigenous peoples in these regions than non-Indigenous populations. In the included studies, Indigenous peoples showed a higher number of epilepsy hospital presentations, decreased access to specialists, decreased access and longer waits for antiseizure medication, and increased prescriptions for enzyme-inducing antiseizure medications when compared with non-Indigenous peoples. In Australia, the number of disability-adjusted life years among Aboriginal and Torres Strait Islander peoples with epilepsy was double that for non-Indigenous people with epilepsy. Mortality rates for Indigenous peoples with epilepsy in New Zealand and Australia were higher than in non-Indigenous people with epilepsy.

INTERPRETATION

Although Indigenous people from CANZUS have unique cultural identities, this review identified similar themes and substantial disparities experienced by Indigenous versus non-Indigenous people in these nations. Concerningly, there were relatively few studies, and these were of variable quality, leaving substantial knowledge gaps. Epidemiological epilepsy research in each specific Indigenous group from CANZUS countries is urgently required to enable health policy development and minimise inequity within these countries.

FUNDING

Health Research Council of New Zealand.

Statistical Accuracy of Administratively Recorded Race/Ethnicity in the Military Health System and Race/Ethnicity Ascertained via Questionnaire

BACKGROUND

Unequal disease burdens such as SARS-CoV-2 infection rates and COVID-19 outcomes across race/ethnicity groups have been reported. Misclassification of and missing race and ethnicity (race/ethnicity) data hinder efforts to identify and address health disparities in the US Military Health System (MHS); therefore, we evaluated the statistical accuracy of administratively recorded race/ethnicity data in the MHS Data Repository (MDR) through comparison to self-reported race/ethnicity collected via questionnaire in the Epidemiology, Immunology, and Clinical Characteristics of Emerging Infectious Diseases with Pandemic Potential (EPICC) cohort study.

METHODS

The study population included 6009 active duty/retired military (AD/R) and dependent beneficiaries (DB). Considering EPICC study responses the "gold standard," we calculated sensitivity and positive predictive value (PPV) by race/ethnicity category (non-Hispanic (NH) White, NH Black, Hispanic, NH Asian/Pacific Islander (A/PI), NH American Indian/Alaskan Native (AI/AN), NH Other, missing/unknown).

RESULTS

Among AD/R, the highest sensitivity and PPV values were for NH White (0.93, 0.96), NH Black (0.90, 0.92), Hispanic (0.80, 0.93), and NH A/PI (0.84, 0.95) and lowest for NH AI/AN (0.62, 0.57) and NH Other (0.09, 0.03). The MDR was missing race/ethnicity data for approximately 63% of DB and sensitivity values, though not PPV, were comparatively much lower: NH White (0.35, 0.88), NH Black (0.55, 0.89), Hispanic (0.13, 1.00), and NH A/PI (0.28, 0.84).

CONCLUSIONS

Our evaluation of MDR race/ethnicity data revealed misclassification, particularly among some minority groups, and substantial missingness among DB. The potential bias introduced impacts the ability to address health disparities and conduct health research in the MHS, including studies of COVID-19, and needs further examination.

Hospice Use Among Medicare Beneficiaries With Parkinson Disease and Dementia With Lewy Bodies

Importance

Neurodegenerative disorders are now the most common reason that Medicare beneficiaries enroll in hospice for end-of-life care. People with all-cause dementia have high rates of suboptimal hospice use, but little is known about hospice use patterns in Lewy body disease, which includes both Parkinson disease (PD) and dementia with Lewy bodies (DLB).

Objective

To compare patient characteristics, hospice agency characteristics, and patterns of use for beneficiaries with PD and DLB vs Alzheimer disease (AD).

Design, Setting, and Participants

A retrospective cohort study including a 100% sample of national 2010-2020 calendar year Medicare data on hospice enrollees was performed. Data analysis was conducted from November 2023 to May 2024.

Exposures

A diagnosis of PD or DLB, compared with AD as the reference group.

Main Outcomes and Measures

Proportion of enrollees with short stays (<7 days), proportion with long stays (>180 days), proportion disenrolled for any reason before death, and disenrollment by type.

Results

Of 11 327 324 Medicare beneficiaries enrolled in hospice between 2010 and 2020 who met eligibility criteria (mean [SD] age, 85.2 [7.5] years; 781 763 [63.0%] female), there were 958 182 (8.4%) with a primary diagnosis of AD, 232 864 (2.1%) with PD, and 49 340 (0.4%) with DLB. People with PD were more likely to experience a long stay (odds ratio [OR], 1.15; 95% CI, 1.13-1.16) compared with AD, whereas the odds for those with DLB were not increased. However, people with either PD or DLB were less likely to be disenrolled for extended prognosis compared with AD (OR for DLB, 0.82; 95% CI, 0.79-0.85; OR for PD, 0.86; 95% CI, 0.85-0.88). People with PD were more likely to revoke hospice (OR, 1.29; 95% CI, 1.27-1.32) compared with AD.

Conclusions and Relevance

In this cohort study of Medicare beneficiaries, hospice use patterns differed by dementia subtype. Higher likelihood of hospice revocation in PD raises important questions about unmet needs and highlights the need for more research around the experience of the end of life in this growing population.

Mediators of Racial Inequities in Non-Small Cell Lung Cancer Care

BACKGROUND

Black patients with non-small cell lung cancer (NSCLC) are more often diagnosed at a later stage and receive inadequate evaluation and treatment compared to White patients. We aimed to identify factors representing exposure to structural racism that mediate the association between race and NSCLC care.

METHODS

We queried Surveillance, Epidemiology, and End Results-Medicare for non-Hispanic Black and White patients ≥ 67 years diagnosed with NSCLC from 2013 to 2019. Our outcomes were localized diagnosis stage, receipt of stage-appropriate evaluation, receipt of stage-appropriate treatment, two-year survival, and receipt of "optimal" care, an aggregate metric comprising the first three listed outcomes. We estimated indirect effects of mediators on the association between race and outcomes.

RESULTS

Of 69,130 patients, 8.2% were Black. Medicare-Medicaid dual eligibility, a marker of individual-level socioeconomic status (SES), accounted for the largest proportion of mediating effects for most outcomes, ranging from 13.6% (p < 0.001) for localized diagnosis stage to 25.0% (p < 0.001) for two-year survival. Receipt of an influenza vaccine, a marker of health care access, had the second largest mediating effects on the associations between race and diagnosis stage (9.5%, p < 0.001), treatment (15.3%, p < 0.001), and optimal care (11.4%, p < 0.001). Neighborhood-level SES accounted for the third largest proportion of the effects of race on each outcome, explaining between 9% and 16% of the racial inequities at each phase (all p < 0.001).

CONCLUSIONS

Individual- and neighborhood-level structural factors partly explain inequities in NSCLC care, and their effects vary based on the phase of care. Interventions should be adapted to the phase of care.

Antipsychotic Use in Older Adults with Dementia: Community and Nursing Facility Trends in Texas, 2015-2020

OBJECTIVES

To assess recent trends in antipsychotic use among older adults with Alzheimer's disease and related dementias (ADRDs) according to their residential status and determine the factors associated with the use of antipsychotics.

DESIGN

Population-based, cross-sectional study using Texas Medicare Fee-for-Service data.

SETTING AND PARTICIPANTS

Individuals aged ≥ 65 years with ADRDs who had at least 3 months of Medicare Part A and B, and Part D for prescription drug coverage, in any year between 2015 and 2020.

METHODS

Temporal trends for antipsychotic use were reported by calendar year, and the associations between antipsychotic use and potential predictors were assessed overall and by residential status.

RESULTS

Among an annual average of 161,848 older adults with ADRDs (median age, 82 years; 64.8% female), overall antipsychotic use decreased by 25.8%, from 14.5% in 2015 to 10.8% in 2020. The decline was primarily observed among those with any nursing facility (NF) residence, where use dropped from 22.1% to 12.4%, whereas community-dwelling individuals maintained a steady rate of approximately 10%. Factors associated with increased antipsychotic use included male sex, Black and Hispanic individuals, dual eligibility, Alzheimer's disease (non-Alzheimer's disease), emergency department visits, hospitalization, depression, and anxiety disorders. However, these associations varied across residential statuses. Older age was more strongly associated with decreased antipsychotic use among those with NF residence than those in the community. Compared with white individuals, Black individuals were more likely to receive antipsychotics in the community, whereas Hispanic and Asian individuals were more likely to receive antipsychotics among those with NF residence.

CONCLUSIONS AND IMPLICATIONS

Although antipsychotic use substantially decreased among those with NF residence, it remained steady among community-dwelling individuals. Given that two-thirds of individuals with dementia reside in the community, more attention is needed to understand antipsychotic use in this population.

Race and Ethnicity Disparities in Cardiovascular and Cancer Mortality: the Role of Socioeconomic Status-a Systematic Review and Meta-analysis

To clarify the role of socioeconomic status (SES) in cardiovascular and cancer mortality disparities observed between Black, Hispanic, and Asian compared to White adults, we conducted a meta-analysis of the longitudinal research in the USA. A PubMed, Ovid Medline, Web of Science, and EBSCO search was performed from January 1995 to May 2023. Two authors independently screened the studies and conducted risk assessments, with conflicts resolved via consensus. Studies were required to analyze mortality data using Cox proportional hazard regression. Random-effects models were used to pool hazard ratios (HR) and reporting followed PRISMA guidelines. Twenty-two studies with cardiovascular mortality (White and Black (n = 22), Hispanic (n = 7), and Asian (n = 3) adults) and twenty-three with cancer mortality endpoints (White and Black (n = 23), Hispanic (n = 11), and Asian (n = 10) adults) were included. The meta-analytic sample for cardiovascular mortality endpoints was 6,199,049 adults (White = 4,891,735; Black = 935,002; Hispanic = 295,623; Asian = 76,689), while for cancer-specific mortality endpoints was 7,745,180 adults (White = 5,988,392; Black= 1,070,447; Hispanic= 484,848; Asian = 201,493). Median follow-up was 10 and 11 years in cohorts with cardiovascular and cancer mortality endpoints, respectively. Adjustments for SES attenuated the higher risk for cardiovascular (HR, 1.46; 95% CI, 1.30-1.64) and cancer mortality (HR, 1.35; 95% CI, 1.32-1.38) of Black compared to White adults by 25% (HR, 1.21; 95% CI, 1.15-1.28) and 19% (HR, 1.16; 95% CI, 1.13-1.18), respectively. However, the Hispanic cardiovascular (HR, 0.79; 95% CI, 0.73-0.85) and Asian cancer mortality (HR, 0.81; 95% CI, 0.76-0.86) advantage were independent of SES. These findings emphasize the need to develop strategies focused on SES to reduce cardiovascular and cancer mortality in Black adults.

Algorithms to Improve Fairness in Medicare Risk Adjustment

Importance

Payment system design creates incentives that impact healthcare spending, access, and outcomes. With Medicare Advantage accounting for more than half of Medicare spending, changes to its risk adjustment algorithm have the potential for broad consequences.

Objective

To develop risk adjustment algorithms that can achieve fair spending targets, and compare their performance to a baseline that emulates the least squares regression approach used by the Centers for Medicare and Medicaid Services.

Design

Retrospective analysis of Traditional Medicare enrollment and claims data between January 2017 and December 2020. Diagnoses in claims were mapped to Hierarchical Condition Categories (HCCs). Algorithms used demographic indicators and HCCs from one calendar year to predict Medicare spending in the subsequent year.

Setting

Data from Medicare beneficiaries with documented residence in the United States or Puerto Rico.

Participants

A random 20% sample of beneficiaries enrolled in Traditional Medicare. Included beneficiaries were aged 65 years and older, and did not have Medicaid dual eligibility. Race/ethnicity was assigned using the Research Triangle Institute enhanced indicator.

Main Outcome and Measures

Prospective healthcare spending by Medicare. Overall performance was measured by payment system fit and mean absolute error. Net compensation was used to assess group-level fairness.

Results

The main analysis included 4,398,035 Medicare beneficiaries with a mean age of 75.2 years and mean annual Medicare spending of $8,345. Out-of-sample payment system fit for the baseline regression was 12.7%. Constrained regression and post-processing both achieved fair spending targets, while maintaining payment system fit values of 12.6% and 12.7%, respectively. Whereas post-processing only increased mean payments for beneficiaries in minoritized racial/ethnic groups, constrained regression increased mean payments for beneficiaries in minoritized racial/ethnic groups and beneficiaries in other groups residing in counties with greater exposure to socioeconomic factors that can adversely affect health outcomes.

Conclusions and Relevance

Constrained regression and post-processing can incorporate fairness objectives in the Medicare risk adjustment algorithm with minimal reduction in overall fit.

Comparing traditional and causal inference methodologies for evaluating impacts of long-term air pollution exposure on hospitalization with Alzheimer disease and related dementias

Alzheimer disease and related dementias (ADRDs) present a growing public health burden in the United States. One actionable risk factor for ADRDs is air pollution: multiple studies have found associations between air pollution and exacerbation of ADRDs. Our study builds on previous studies by applying modern statistical causal inference methodologies-generalized propensity score (GPS) weighting and matching-on a large, longitudinal data set. We follow 50 million Medicare enrollees to investigate impacts of 3 air pollutants-fine particular matter (PM2.5), nitrogen dioxide (NO2), and summer ozone (O3)-on elderly patients' rate of first hospitalization with an ADRD diagnosis. Similar to previous studies using traditional statistical models, our results found increased hospitalization risks due to increased PM2.5 and NO2 exposure, with less conclusive results for O3. In particular, our GPS weighting analysis finds IQR increases in PM2.5, NO2, or O3 exposure result in hazard ratios of 1.108 (95% CI, 1.097, 1.119), 1.058 (1.049-1.067), or 1.045 (1.036-1.054), respectively. GPS matching results are similar for PM2.5 and NO2 with attenuated effects for O3. Our results strengthen arguments that long-term PM2.5 and NO2 exposure increases risk of hospitalization with an ADRD diagnosis. Additionally, we highlight strengths and limitations of causal inference methodologies in observational studies with continuous treatments. This article is part of a Special Collection on Environmental Epidemiology.

Variation in the time to complete the primary COVID-19 vaccine series by race, ethnicity, and geography among older US adults

INTRODUCTION

Racial and ethnic disparities in COVID-19 vaccine access are well-documented; however, few studies have examined whether racial disparities are modified by other factors, including geographic location and area-level deprivation.

METHODS

We conducted an observational study using the COVVAXAGE database. Medicare beneficiaries who received the COVID-19 vaccine primary series (two doses) between 01/01/2021 and 12/31/2021 were included. Racial differences in the time between doses was assessed by urbanicity using g-formula methods.

RESULTS

We identified 11,924,990 beneficiaries (mean age = 75.4; 60 % female; 80 % White). Most beneficiaries (97.1 %) received their second vaccine on time. Delayed second doses were more common among beneficiaries who were Black (RRdelayed = 1.30, 95 %CI = 1.28-1.31) and rural (RRdelayed = 1.27, 95 %CI = 1.25-1.29) relative to White and urban beneficiaries. Racial disparities in delayed vaccinations varied in magnitude by degree of urbanicity.

CONCLUSIONS

Most beneficiaries received their second COVID-19 vaccine on time. Racial disparities were observed and shown to vary by geographic area.

Primer on Health Equity Research in Health Economics and Outcomes Research: An ISPOR Special Interest Group Report

OBJECTIVES

Disparities in health and healthcare between more and less socially advantaged groups are pervasive, multidimensional, and far-reaching. The material and social conditions in which people are born, grow, work, live, and age are systematically associated with their health and with the volume, quality, and outcomes of care received by the vast majority of the general population, as well as by specific marginalized populations. The field of health economics and outcomes research (HEOR) has an important role in supporting health equity goals. This publication aimed to act as a "primer" for conducting health equity research within the field of HEOR, establishing foundational understanding of key concepts.

METHODS

The ISPOR Special Interest Group on Health Equity Research was established in 2021 to advance equity-informative methods and data to better enable researchers to empirically investigate-and ultimately reduce-unfair social differences in health. This publication was developed by the ISPOR Special Interest Group leadership team with input from the group membership.

RESULTS

The resultant publication provides an overview of health equity research methods and data considerations as they relate to HEOR-relevant topics including clinical trials, real-world evidence and economic evaluation. Reflecting the current body of research on health equity in HEOR, particular focus is given to the latter. It also brings together a list of core reference material to support future learning.

CONCLUSIONS

This report provides the HEOR community with a tailored "state of play" overview of health equity, to support development of foundational understanding and inspire increased engagement.

Cervical Cancer Screening Utilization among Kidney Transplant Recipients, 2001 to 2018

BACKGROUND

Kidney transplant recipients (KTR) have elevated risks of cervical precancers and cancers and guidelines recommend more frequent cervical cancer screening exams. However, little is known about current trends in cervical cancer screening in this unique population. We described patterns in the uptake of cervical cancer screening exams among female KTRs and identified factors associated with screening utilization.

METHODS

This retrospective cohort study included female KTRs between 20 and 65 years old, with Texas Medicare fee-for-service coverage, who received a transplant between January 1, 2001, and December 31, 2017. We determined the cumulative incidence of receiving cervical cancer screening post-transplant using ICD-9, ICD-10, and CPT codes and assessed factors associated with screening utilization, using the Fine and Gray model to account for competing events. Subdistribution hazard models were used to assess factors associated with screening uptake.

RESULTS

Among 2,653 KTRs meeting the inclusion and exclusion criteria, the 1-, 2-, and 3-year cumulative incidences of initiating a cervical cancer screening exam post-transplant were 31.7% [95% confidence interval (CI), 30.0%-33.6%], 48.0% (95% CI, 46.2%-49.9%), and 58.5% (95% CI, 56.7%-60.3%), respectively. KTRs who were 55 to 64 years old (vs. <45 years old) and those with a higher Charlson Comorbidity Score post-transplant were less likely to receive cervical cancer screening post-transplant.

CONCLUSIONS

Cervical cancer screening uptake is low in the years immediately following a kidney transplant.

IMPACT

Our findings highlight a need for interventions to improve cervical cancer screening utilization among kidney transplant recipients. See related In the Spotlight, p. 1554.

Indigenous access to clinical services along the lung cancer treatment pathway: a review of current evidence

BACKGROUND

Lung cancer is a deadly cancer. Early diagnosis and access to timely treatment are essential to maximizing the likelihood of survival. Indigenous peoples experience enduring disparities in lung cancer survival, and disparities in access to and through lung cancer services is one of the important drivers of these disparities. In this manuscript, we aimed to examine the current evidence on disparities in Indigenous access to services along the lung cancer treatment pathway.

METHODS

A narrative literature review was conducted for all manuscripts and reports published up until July 20, 2022, using Medline, Scopus, Embase, and Web of Science. Following the identification of eligible literature, full-text versions were scanned for relevance for inclusion in this review, and relevant information was extracted. After scanning 1,459 documents for inclusion, our final review included 36 manuscripts and reports that included information on lung cancer service access for Indigenous peoples relative to non-Indigenous peoples. These documents included data from Aotearoa New Zealand, Australia, Canada, and the USA (including Hawai'i).

RESULTS

Our review found evidence of disparities in access to, and the journey through, lung cancer care for Indigenous peoples. Disparities were most obvious in access to early detection and surgery, with inconsistent evidence regarding other components of the pathway.

CONCLUSION

These observations are made amid relatively scant data in a global sense, highlighting the need for improved data collection and monitoring of cancer care and outcomes for Indigenous peoples worldwide. Access to early detection and guideline-concordant treatment are essential to addressing enduring disparities in cancer survival experienced by Indigenous peoples globally.

Community-Level Social Vulnerability and Hip and Knee Joint Replacement Surgery Receipt Among Medicare Enrollees With Arthritis

OBJECTIVES

(1) Explore associations between county minority health social vulnerability index (MH-SVI) and total joint replacement (TJR), and (2) assess associations by individual-level race/ethnicity.

BACKGROUND

An expanded understanding of relevant social determinants of health is essential to inform policies and practices that promote equitable access to hip and knee TJR.

METHODS

Retrospective cohort study of Medicare enrollees. Centers for Medicare and Medicaid Services claims data were linked with MH-SVI. Multivariable logistic regression models were used to evaluate the odds of TJR according to the MH-SVI quartile in which enrollees resided. A total of 10,471,413 traditional Medicare enrollees in 2018 aged 67 years or older with arthritis. The main outcome was enrollee primary TJR during hospitalization. The main exposure was the MH-SVI (composite and 6 themes) for the county of enrollee residence. Results were stratified by enrollee race/ethnicity.

RESULTS

Asian American, Native Hawaiian, or Pacific Islander (AANHPI), Black or African American (Black), and Hispanic enrollees comparatively had 26%-41% lower odds of receiving TJR than White enrollees. Residing in counties within the highest quartile of composite and socioeconomic status vulnerability measures were associated with lower TJR overall and by race/ethnicity. Residing in counties with increased medical vulnerability for Black and White enrollees, housing type and transportation vulnerability for AANHPI and Hispanic enrollees, minority status and language theme for AANHPI enrollees, and household composition vulnerability for White enrollees were also associated with lower TJR.

CONCLUSIONS

Higher levels of social vulnerability were associated with lower TJR. However, the association varied by individual race/ethnicity. Implementing multisectoral strategies is crucial for ensuring equitable access to care.

Variation in organisational factors across high- and low-performing hospitals with regard to spontaneous vaginal birth for Black women in four states: a cross-sectional descriptive study

OBJECTIVE

To describe variation in hospital organisational factors across high- and low-performing hospitals with regard to spontaneous vaginal birth (SVB) for Black women.

DESIGN

Cross-sectional descriptive.

SETTING

We conducted a cross-sectional study using three datasets in four states from 2016, including the American Hospital Association Annual Survey, administrative discharge abstracts and a survey in which nurses served as informants about the organisational factors in their hospitals. Hospitals were categorised based on whether they achieved (1) the SVB rate target for Black women at low risk for caesarean birth, (2) the SVB rate target for Black women at low risk for caesarean birth and equivalent SVB rates between Black and White women at low risk for caesarean birth, or (3) neither of these metrics. The first two categories above were considered 'high performing' and the third 'low performing'. Analysis of variances were used to compare organisational factors between hospital categories.

PARTICIPANTS

There were 257 hospitals in the sample.

PRIMARY AND SECONDARY OUTCOME MEASURES

Outcomes were meeting the SVB rate targets for Black women at low risk for caesarean birth and SVB rate equivalence between Blacks and White patients.

RESULTS

High-performing hospitals had better nurse work environments (2.84 vs 2.695, p =0.04), including better nurse-physician relationships (2.77 vs 2.695, p =0.02). There were statistically significantly more advanced practice nurses (APNs) on average in maternity units in high-performing hospitals compared with low performing (3.51 to 2.76; p=0.003).

CONCLUSIONS

Better rated nurse work environments and the presence of APNs were distinguishing characteristics of high-performing hospitals. These organisational factors may be system-level targets for hospital-level interventions to improve SVB rates and equity therein.

Prescription Fills Among Patients With Type 2 Diabetes After Hospitalization for Acute Coronary Syndrome

Importance

Individuals with type 2 diabetes (T2D) have high rates of mortality following myocardial infarction (MI). Hospitalization is an opportunity to initiate or continue evidence-based treatment to reduce risk in individuals with T2D and acute coronary syndrome (ACS).

Objective

To determine patterns of evidence-based medication use during the period of transition from admission to discharge after hospitalization for MI or coronary revascularization among individuals with T2D and ACS.

Design, Setting, and Participants

This retrospective cohort study used data from the Centers for Medicare & Medicaid Services (CMS) for January 1, 2018, to June 30, 2020. Medicare beneficiaries older than 18 years with T2D with a qualifying hospitalization were included. Individuals were followed before admission (90 days prior), at discharge (≤90 days), and after discharge (91-180 days after) from a hospitalization for MI or coronary revascularization. Data analysis was performed in June 2023.

Exposures

Demographic data (race, sex, rural vs urban location of care, and comorbidities) were abstracted from CMS data using Master Beneficiary and Summary Files and International Statistical Classification of Diseases, Tenth Revision codes.

Main Outcome and Measures

Medicare Part D prescription fill records were examined for the following agents: (1) angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), or angiotensin receptor-neprilysin inhibitors (ARNIs); (2) β-blockers; (3) platelet adenosine diphosphate receptor inhibitors (P2Y12Is); (4) statins or proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9Is); and (5) glucagon-like peptide 1 receptor agonists (GLP-1RAs) or sodium glucose cotransporter 2 inhibitors (SGLT2Is). Logistic regression analysis was used to examine the association between covariates and lack of prescription fills in the postdischarge period.

Results

A total of 188 651 eligible Medicare beneficiaries with T2D and hospitalization for MI or coronary revascularization were identified. Their median age was 73.0 (IQR, 67.0-79.0) years, and more than half (111 982 [59.4%]) were men; 18 383 (9.7%) were Black and 153 461 (81.3%) were White. Not filling a cardiovascular medication after hospitalization was associated with not filling that medication at the time of discharge (adjusted risk ratio, 0.27 [95% CI, 0.27-0.28] for ACEIs, ARBs, or ARNIs; 0.24 [0.24-0.25] for β-blockers; 0.20 [0.19-0.20] for P2Y12Is; 0.31 [0.31-0.32] for statins or PCSK9Is; and 0.27 [0.26-0.28] for SGLT2Is or GLP-1RAs).

Conclusions and Relevance

In this cohort study of Medicare beneficiaries with T2D, longer-term medication use following hospitalization for MI was associated with medication use at the time of discharge. These findings highlight the critical importance of this period to optimize preventive care for these high-risk individuals. Further implementation science research is needed to develop strategies to improve use of these evidence-based medications.

Home Health Care and Place of Death in Medicare Beneficiaries With and Without Dementia

BACKGROUND AND OBJECTIVES

Home health care supports patient goals for aging in place. Our objective was to determine if home health care use in the last 3 years of life reduces the risk of inpatient death without hospice.

RESEARCH DESIGN AND METHODS

We analyzed the characteristics of 2,065,300 Medicare beneficiaries who died in 2019 and conducted multinomial logistic regression analyses to evaluate the association between the use and timing of home health care, dementia diagnosis, and place of death.

RESULTS

Receiving any home health care in the last 3 years of life was associated with a lower probability of inpatient death without hospice (Pr 23.3% vs 31.5%, p < .001), and this effect was stronger when home health care began prior to versus during the last year of life (Pr 22.5% vs 24.3%, p < .001). Among all decedents, the probability of death at home with hospice compared to inpatient death with hospice was greater when any home health care was used (Pr 46.0% vs 36.5%, p < .001), and this association was strongest among beneficiaries with dementia who started home health care at least 1 year prior to death (Pr 55.6%, p < .001).

DISCUSSION AND IMPLICATIONS

Use of home health care during the last 3 years of life was associated with reduced rates of inpatient death without hospice, and increased rates of home death with hospice. Increasing affordable access to home health care can positively affect end-of-life care outcomes for older Americans and their family caregivers, especially those with dementia.

Association between tissue loss type and amputation risk among Medicare patients with concomitant diabetes and peripheral arterial disease

OBJECTIVE

Prior studies have described risk factors associated with amputation in patients with concomitant diabetes and peripheral arterial disease (DM/PAD). However, the association between the severity and extent of tissue loss type and amputation risk remains less well-described. We aimed to quantify the role of different tissue loss types in amputation risk among patients with DM/PAD, in the context of demographic, preventive, and socioeconomic factors.

METHODS

Applying International Classification of Diseases (ICD)-9 and ICD-10 codes to Medicare claims data (2007-2019), we identified all patients with continuous fee-for-service Medicare coverage diagnosed with DM/PAD. Eight tissue loss categories were established using ICD-9 and ICD-10 diagnosis codes, ranging from lymphadenitis (least severe) to gangrene (most severe). We created a Cox proportional hazards model to quantify associations between tissue loss type and 1- and 5-year amputation risk, adjusting for age, race/ethnicity, sex, rurality, income, comorbidities, and preventive factors. Regional variation in DM/PAD rates and risk-adjusted amputation rates was examined at the hospital referral region level.

RESULTS

We identified 12,257,174 patients with DM/PAD (48% male, 76% White, 10% prior myocardial infarction, 30% chronic kidney disease). Although 2.2 million patients (18%) had some form of tissue loss, 10.0 million patients (82%) did not. The 1-year crude amputation rate (major and minor) was 6.4% in patients with tissue loss, and 0.4% in patients without tissue loss. Among patients with tissue loss, the 1-year any amputation rate varied from 0.89% for patients with lymphadenitis to 26% for patients with gangrene. The 1-year amputation risk varied from two-fold for patients with lymphadenitis (adjusted hazard ratio, 1.96; 95% confidence interval, 1.43-2.69) to 29-fold for patients with gangrene (adjusted hazard ratio, 28.7; 95% confidence interval, 28.1-29.3), compared with patients without tissue loss. No other demographic variable including age, sex, race, or region incurred a hazard ratio for 1- or 5-year amputation risk higher than the least severe tissue loss category. Results were similar across minor and major amputation, and 1- and 5-year amputation outcomes. At a regional level, higher DM/PAD rates were inversely correlated with risk-adjusted 5-year amputation rates (R2 = 0.43).

CONCLUSIONS

Among 12 million patients with DM/PAD, the most significant predictor of amputation was the presence and extent of tissue loss, with an association greater in effect size than any other factor studied. Tissue loss could be used in awareness campaigns as a simple marker of high-risk patients. Patients with any type of tissue loss require expedited wound care, revascularization as appropriate, and infection management to avoid amputation. Establishing systems of care to provide these interventions in regions with high amputation rates may prove beneficial for these populations.

Association Between State-Wide Cardiac Quality Improvement Program and Costs Following Intervention for Coronary Artery Disease

BACKGROUND

Since 2010, all non-VA hospitals performing cardiac surgeries and percutaneous interventions in Washington State have participated in the Cardiac Care Outcomes Assessment Program (COAP), a data-driven, physician-led collaborative quality improvement (QI) collaborative. Prior literature has demonstrated QI programs such as COAP can avert avoidable utilization such as hospital readmissions. However, it is unknown whether such improvements translate into economic benefits.

HYPOTHESIS

This study compared downstream healthcare costs between patients undergoing cardiac interventions for coronary artery disease (CAD) at hospitals that were and were not participating in COAP.

METHODS

Post hoc analysis of Medicare administrative and claims data examined 2.5 million randomly selected deidentified beneficiaries receiving a percutaneous coronary intervention or coronary artery bypass grafting between 2013 and 2020. Total costs were defined as all reimbursements paid by Medicare for up to 5 years following cardiac intervention. Because all non-VA hospitals in Washington State participated in COAP, we compared respective groups of patients receiving intervention in Washington State with all non-Washington states, adjusting for patient demographics and comorbidity. To model costs, we applied a multipart estimator, which distinguishes the impact of QI program participation due to survival and utilization while accounting for censoring.

RESULTS

Total 5-year downstream costs were $3861 lower (95% confidence interval [CI] = $1794 to $5741) among patients receiving cardiac intervention at COAP-exposed hospitals. Lower costs were largely driven by lower utilization during calendar quarters where death was not observed.

CONCLUSIONS

Participation in this state-wide cardiac quality improvement program was associated with economic benefits in patients receiving intervention for CAD.

The effect of air pollution on hospitalizations with Parkinson's disease among medicare beneficiaries nationwide

We examined the effect of annual exposure to fine particulate matter (PM2.5), nitrogen dioxide (NO2), and ozone (O3), on the rate of first hospitalization with a PD-related diagnosis (hospitalization with PD) among Medicare Fee-for-Service beneficiaries (2001-2016). Machine learning-derived annual air pollution concentrations were linked to residential ZIP codes. For each exposure, we fitted four models: 1) traditional outcome stratification, 2) marginal structural, 3) doubly robust, and 4) generalized propensity score matching Poisson regression models, adjusted for sociodemographic and meteorological confounders and long-term trends. Among 49,121,026 beneficiaries, incidence rate ratios of 1.08 (95% CI: 1.07, 1.10), 1.07 (95% CI: 1.05, 1.08), and 1.03 (95% CI: 1.02, 1.05) for an interquartile range increase in PM2.5 (3.72 µg/m3), NO2 (13.84 ppb), and O3 (10.09 ppb), respectively, were estimated from doubly robust models. Results were similar across modeling approaches. In this nationwide study, higher air pollution exposure increased the rate of hospitalizations with PD.

Incident Epilepsy Among US Medicare Beneficiaries, 2019: Differences by Age, Sex, and Race/Ethnicity

BACKGROUND AND OBJECTIVES

Epilepsy is common among older adults, but previous incident studies have had limited ability to make comparisons across key subgroups. We aimed to provide updated epilepsy incidence estimates among older adults, comparing across age, sex, and race/ethnicity.

METHODS

Using a random sample of 4,999,999 US Medicare beneficiaries older than 65 years, we conducted a retrospective cohort study of epilepsy incidence using administrative claims for 2016-2019. Sampled beneficiaries were enrolled in the Fee-for-Service (FFS) program in each of 2016-2018 and had no epilepsy claims in those years. Non-Hispanic Black and Hispanic beneficiaries were oversampled to ensure adequate cases for detailed comparisons. Incidence in 2019 was identified in the Master Beneficiary Summary File as ≥1 inpatient claim or ≥2 outpatient nondrug claims occurring at least 1 day apart (ICD-10 G40.x). Incidence models were estimated by age, sex, race/ethnicity, and combinations thereof, with adjustment for the racial/ethnic oversampling.

RESULTS

We identified 20,545 incident epilepsy cases. The overall epilepsy incidence rate (IR) was 393 per 100,000 (99% CI 385-400). Incidence peaked at ages 85-89 (504 [481-529]) and was higher for men (396 [385-407]) than women (376 [366-385]). The sex difference in IRs was constant with age. Incidence was higher for non-Hispanic Black (678 [653-702]) and Hispanic (405 [384-426]), and lower for non-Hispanic Asian/Pacific Islander (272 [239-305]) beneficiaries, compared with non-Hispanic White beneficiaries (354 [299-408]). The age-specific IRs significantly differed by race/ethnicity and sex, but only among non-Hispanic Black beneficiaries-where men had higher rates at younger ages and women at older ages.

DISCUSSION

We found higher epilepsy IRs among those enrolled in the Medicare FFS system 2016-2019 than previous studies using Medicare claims data from at least a decade ago. The risk of epilepsy onset is higher for those in their late 80s, men, and non-Hispanic Black and Hispanic older adults. There is also evidence that these age-graded risks operate differently for Black men and Black women. Efforts to provide care and services that improve quality of life for older adults living with epilepsy should consider differences by multiple social characteristics simultaneously: age, sex, and race/ethnicity.

Regional variation in diagnostic intensity of dementia among older U.S. adults: An observational study

INTRODUCTION

Geographic variation in diagnosed cases of Alzheimer's disease and related dementias (ADRD) could be due to underlying population risk or differences in intensity of new case identification. Areas with low ADRD diagnostic intensity could be targeted for additional surveillance efforts.

METHODS

Medicare claims were used for a cohort of older adults across hospital referral regions (HRRs). ADRD-specific regional diagnosis intensity was measured as the ratio of expected new ADRD cases (estimated using population demographics, risk factors, and practice intensity) compared to observed ADRD-diagnosed cases.

RESULTS

Crude new ADRD diagnosis rate ranged from 1.7 to 5.4 per 100 across HRRs. ADRD-specific diagnosis intensity ranged from 0.69 to 1.47 and varied most for Black, Hispanic, and the youngest (66-74) subgroups. Across all subgroups, ADRD diagnosis intensity was associated with 2-fold difference in receiving an ADRD diagnosis.

DISCUSSION

Where one resides influences the likelihood of receiving an ADRD diagnosis, particularly among those 66-74 years of age and minoritized groups.

HIGHLIGHTS

Rate of new Alzheimer's disease and related dementias (ADRD) case identification varies geographically across the United States. Variation in case identification is greatest in Black, Hispanic, and young-old groups. Intensity of diagnosis (ie, case identification) unrelated to population risk differs across place. Likelihood of receiving an ADRD diagnosis varies 2-fold based on place of residence.

Social Determinants of Health and Surgical Desirability of Outcome Ranking in Older Veterans

Importance

Evaluating how social determinants of health (SDOH) influence veteran outcomes is crucial, particularly for quality improvement.

Objective

To measure associations between SDOH, care fragmentation, and surgical outcomes using a Desirability of Outcome Ranking (DOOR).

Design, Setting, And Participants

This was a cohort study of US veterans using data from the Veterans Affairs (VA) Surgical Quality Improvement Program (VASQIP; 2013-2019) limited to patients aged 65 years or older with inpatient stays between 2 and 30 days, merged with multiple data sources, including Medicare. Race and ethnicity data were retrieved from VASQIP, Medicare and Medicaid beneficiary summary files, the Veterans Health Administration Corporate Data Warehouse, and the United States Veterans Eligibility Trends and Statistics file. Data were analyzed between September 2023 and February 2024.

Exposure

Living in a highly deprived neighborhood (Area Deprivation Index >85), race and ethnicity used as a social construct, rurality, and care fragmentation (percentage of non-VA care days).

Main Outcomes and Measures

DOOR is a composite, patient-centered ranking of 26 outcomes ranging from no complication (1, best) to 90-day mortality or near-death complications (6, worst). A series of proportional odds regressions was used to assess the impact of SDOH and care fragmentation adjusted for clinical risk factors, including presentation acuity (presenting with preoperative acute serious conditions and urgent or emergent surgical procedures).

Results

The cohort had 93 644 patients (mean [SD] age, 72.3 [6.2] years; 91 443 [97.6%] male; 74 624 [79.7%] White). Veterans who identified as Black (adjusted odds ratio [aOR], 1.06; 95% CI, 1.02-1.10; P = .048) vs White and veterans with higher care fragmentation (per 20% increase in VA care days relative to all care days: aOR, 1.01; 95% CI, 1.01-1.02; P < .001) were associated with worse (higher) DOOR scores until adjusting for presentation acuity. Living in rural geographic areas was associated with better DOOR scores than living in urban areas (aOR, 0.93; 95% CI, 0.91-0.96; P < .001), and rurality was associated with lower presentation acuity (preoperative acute serious conditions: aOR, 0.88; 95% CI, 0.81-0.95; P = .001). Presentation acuity was higher in veterans identifying as Black, living in deprived neighborhoods, and with increased care fragmentation.

Conclusions and Relevance

Veterans identifying as Black and veterans with greater proportions of non-VA care had worse surgical outcomes. VA programs should direct resources to reduce presentation acuity among Black veterans, incentivize veterans to receive care within the VA where possible, and better coordinate veterans' treatment and records between care sources.

Medical visits and mortality among dementia patients during the COVID-19 pandemic compared to rates predicted from 2019

BACKGROUND

During the COVID-19 pandemic, patients with Alzheimer's disease and related dementias (ADRD) were especially vulnerable, and modes of medical care delivery shifted rapidly. This study assessed the impact of the pandemic on care for people with ADRD, examining the use of primary, emergency, and long-term care, as well as deaths due to COVID and to other causes.

METHODS

Among 4.2 million beneficiaries aged 66 and older with ADRD in traditional Medicare, monthly deaths and claims for routine care (doctors' office and telehealth visits), inpatient/emergency department (ED) visits, and long-term care facility use from March or June 2020 through December 2022 are compared to monthly rates predicted from January-December 2019 using OLS and logistic/negative binomial regression. Correlation analyses examine the association between excess deaths - due to COVID and non-COVID causes - and changes in care use in the beneficiary's state of residence.

RESULTS

Increased telehealth visits more than offset reduced office visits, with primary care visits increasing overall (by 9 percent from June 2020 onward relative to the predicted rate from 2019, p < .001). Emergency/inpatient visits declined (by 9 percent, p < .001) and long-term care facility use declined, remaining 14% below the 2019 trend from June 2020 onward (p < .001). Both COVID and non-COVID deaths rose, with 231,000 excess deaths (16% above the prediction from 2019), over 80 percent of which were attributable to COVID. Excess deaths were higher among women, non-White patients, those in rural and isolated zip codes, and those with higher social deprivation index scores. States with the largest increases in primary care visits had the lowest excess deaths (correlation -0.49).

CONCLUSIONS

Older adults with ADRD had substantial deaths above pre-pandemic projections during the COVID-19 pandemic, 80 percent of which were attributed to COVID-19. Routine care increased overall due to a dramatic increase in telehealth visits, but this was uneven across states, and mortality rates were significantly lower in states with higher than pre-pandemic visits.

Antiretroviral Therapy Use and Disparities Among Medicare Beneficiaries with HIV

BACKGROUND

Antiretroviral therapy (ART) is recommended for all people with HIV. Understanding ART use among Medicare beneficiaries with HIV is therefore critically important for improving quality and equity of care among the growing population of older adults with HIV. However, a comprehensive national evaluation of filled ART prescriptions among Medicare beneficiaries is lacking.

OBJECTIVE

To examine trends in ART use among Medicare beneficiaries with HIV from 2013 to 2019 and to evaluate whether racial and ethnic disparities in ART use are narrowing over time.

DESIGN

Retrospective observational study.

SUBJECTS

Traditional Medicare beneficiaries with Part D living with HIV in 2013-2019.

MAIN MEASURES

Months of filled ART prescriptions each year.

KEY RESULTS

Compared with beneficiaries not on ART, beneficiaries on ART were younger, less likely to be Black (41.6% vs. 47.0%), and more likely to be Hispanic (13.1% vs. 9.7%). While the share of beneficiaries who filled ART prescriptions for 10 + months/year improved (+ 0.48 percentage points/year [p.p.y.], 95% CI 0.34-0.63, p < 0.001), 25.8% of beneficiaries did not fill ART for 10 + months in 2019. Between 2013 and 2019, the proportion of beneficiaries who filled ART for 10 + months improved for Black beneficiaries (65.8 to 70.3%, + 0.66 p.p.y., 95% CI 0.43-0.89, p < 0.001) and White beneficiaries (74.8 to 77.4%, + 0.38 p.p.y.; 95% CI 0.19-0.58, p < 0.001), while remaining stable for Hispanic beneficiaries (74.5 to 75.0%, + 0.12 p.p.y., 95% CI - 0.24-0.49, p = 0.51). Although Black-White disparities in ART use narrowed over time, the share of beneficiaries who filled ART prescriptions for 10 + months/year was significantly lower among Black beneficiaries relative to White beneficiaries each year.

CONCLUSIONS

ART use improved from 2013 to 2019 among Medicare beneficiaries with HIV. However, about 25% of beneficiaries did not consistently fill ART prescriptions within a given year. Despite declining differences between Black and White beneficiaries, concerning disparities in ART use persist.

Trends and Disparities in Ambulatory Follow-Up After Cardiovascular Hospitalizations : A Retrospective Cohort Study

BACKGROUND

Timely follow-up after cardiovascular hospitalization is recommended to monitor recovery, titrate medications, and coordinate care.

OBJECTIVE

To describe trends and disparities in follow-up after acute myocardial infarction (AMI) and heart failure (HF) hospitalizations.

DESIGN

Retrospective cohort study.

SETTING

Medicare.

PARTICIPANTS

Medicare fee-for-service beneficiaries hospitalized between 2010 and 2019.

MEASUREMENTS

Receipt of a cardiology visit within 30 days of discharge. Multivariable logistic regression models were used to estimate changes over time overall and across 5 sociodemographic characteristics on the basis of known disparities in cardiovascular outcomes.

RESULTS

The cohort included 1 678 088 AMI and 4 245 665 HF hospitalizations. Between 2010 and 2019, the rate of cardiology follow-up increased from 48.3% to 61.4% for AMI hospitalizations and from 35.2% to 48.3% for HF hospitalizations. For both conditions, follow-up rates increased for all subgroups, yet disparities worsened for Hispanic patients with AMI and patients with HF who were Asian, Black, Hispanic, Medicaid dual eligible, and residents of counties with higher levels of social deprivation. By 2019, the largest disparities were between Black and White patients (AMI, 51.9% vs. 59.8%, difference, 7.9 percentage points [pp] [95% CI, 6.8 to 9.0 pp]; HF, 39.8% vs. 48.7%, difference, 8.9 pp [CI, 8.2 to 9.7 pp]) and Medicaid dual-eligible and non-dual-eligible patients (AMI, 52.8% vs. 60.4%, difference, 7.6 pp [CI, 6.9 to 8.4 pp]; HF, 39.7% vs. 49.4%, difference, 9.6 pp [CI, 9.2 to 10.1 pp]). Differences between hospitals explained 7.3 pp [CI, 6.7 to 7.9 pp] of the variation in follow-up for AMI and 7.7 pp [CI, 7.2 to 8.1 pp]) for HF.

LIMITATION

Generalizability to other payers.

CONCLUSION

Equity-informed policy and health system strategies are needed to further reduce gaps in follow-up care for patients with AMI and patients with HF.

PRIMARY FUNDING SOURCE

National Institute on Aging.

Provider care segregation and hospital-region racial disparities for carotid interventions in the USA

BACKGROUND

Reasons for racial disparities in the utilization and outcomes of carotid interventions (carotid endarterectomy (CEA) and carotid artery stenting (CAS)) are not well understood, especially segregation of care associated with carotid intervention. We examined patterns of geographic and provider care segregation in carotid interventions and outcomes.

METHOD

We used de-identified Medicare datasets to identify CEA and CAS interventions between January 1, 2016 and December 31, 2019 using validated ICD-10 codes. For patients who underwent carotid intervention, we calculated (1) the proportion of White patients at the hospital, (2) the proportional difference in the proportion of White patients between hospital patients and the county, and (3) provider care segregation by the dissimilarity index for carotid intervention cases. We examined associations between measures of segregation and outcomes.

RESULTS

Despite higher proportions of Black patients in counties with hospitals that provide carotid intervention, lower proportions of Black patients received intervention. The difference in the proportion of White patients comparing CEA patients to the county race distribution was 0.143 (SD 0.297) at the hospital level (for CAS, 0.174 (0.315)). The dissimilarity index for CEA providers was high, with mean (SD) 0.387 (0.274) averaged across all hospitals and higher among CAS providers at 0.472 (0.288). Black patients receiving CEA and CAS (compared with Whites) had reduced odds of discharge home. Better outcomes (inpatient mortality and 30-day mortality) were independently associated with higher proportion of White CAS patients.

CONCLUSION

In this national study with contemporary data on carotid intervention, we found evidence for segregation of care of both CEA and CAS.

Understanding Health Care Disparities Based on Medicare Use for Inflammatory and Infectious Eye Diseases

Purpose

Inflammatory and infectious eye diseases are an important cause of visual impairment in patients older than 65 years of age. Health care disparities for eye care are present for general eye care. However, there is lack of national data on health disparities regarding eye care use for inflammatory and infectious eye diseases. Our study examines the effect of gender and race on eye care in patients with inflammatory and infectious eye diseases who are equal or greater than 65 years of age.

Methods

We have used Medicare data to examine the effect gender and race on use of eye care services in patients with inflammatory and infectious eye diseases for 2014 to 2018. Medicare is a national insurance program administered by the government of United States to insure people age 65 years or older. Owing to its high enrollment, those in Medicare are representative of the U.S. population aged 65 and older.

Results

We found that females have higher use for Medicare for inflammatory and infectious eye diseases across all races from 2014 to 2018. On examining the effect of race, African Americans have lower use as compared with Whites. People of Asian descent have the highest use, followed by Hispanic people.

Conclusions

Health care disparities exist for eye care use for inflammatory and infectious eye diseases for patients 65 years of age and older. Future studies are required to address these disparities to provide equitable eye care.

Translational Relevance

Identification of eye care disparities is the first step to addressing these disparities.

Incorporating Anti-racist Principles Throughout the Research Lifecycle: A Position Statement from the Society of General Internal Medicine (SGIM)

Biomedical research has advanced medicine but also contributed to widening racial and ethnic health inequities. Despite a growing acknowledgment of the need to incorporate anti-racist objectives into research, there remains a need for practical guidance for recognizing and addressing the influence of ingrained practices perpetuating racial harms, particularly for general internists. Through a review of the literature, and informed by the Research Lifecycle Framework, this position statement from the Society of General Internal Medicine presents a conceptual framework suggesting multi-level systemic changes and strategies for researchers to incorporate an anti-racist perspective throughout the research lifecycle. It begins with a clear assertion that race and ethnicity are socio-political constructs that have important consequences on health and health disparities through various forms of racism. Recommendations include leveraging a comprehensive approach to integrate anti-racist principles and acknowledging that racism, not race, drives health inequities. Individual researchers must acknowledge systemic racism's impact on health, engage in self-education to mitigate biases, hire diverse teams, and include historically excluded communities in research. Institutions must provide clear guidelines on the use of race and ethnicity in research, reject stigmatizing language, and invest in systemic commitments to diversity, equity, and anti-racism. National organizations must call for race-conscious research standards and training, and create measures to ensure accountability, establishing standards for race-conscious research for research funding. This position statement emphasizes our collective responsibility to combat systemic racism in research, and urges a transformative shift toward anti-racist practices throughout the research cycle.

Association between claims-based setting of diagnosis and treatment initiation among Medicare patients with hepatitis C

OBJECTIVE

To develop a claims-based algorithm to determine the setting of a disease diagnosis.

DATA SOURCES AND STUDY SETTING

Medicare enrollment and claims data from 2014 to 2019.

STUDY DESIGN

We developed a claims-based algorithm using facility indicators, revenue center codes, and place of service codes to identify settings where HCV diagnosis first appeared. When the first appearance was in a laboratory, we attempted to associate HCV diagnoses with subsequent clinical visits. Face validity was assessed by examining association of claims-based diagnostic settings with treatment initiation.

DATA COLLECTION/EXTRACTION METHODS

Patients newly diagnosed with HCV and continuously enrolled in traditional Medicare Parts A, B, and D (12 months before and 6 months after index diagnosis) were included.

PRINCIPAL FINDINGS

Among 104,454 patients aged 18-64 and 66,726 aged ≥65, 70.1% and 69%, respectively, were diagnosed in outpatient settings, and 20.2% and 22.7%, respectively in laboratory or unknown settings. Logistic regression revealed significantly lower odds of treatment initiation after diagnosis in emergency departments/urgent cares, hospitals, laboratories, or unclassified settings, than in outpatient visits.

CONCLUSIONS

The algorithm identified the setting of HCV diagnosis in most cases, and found significant associations with treatment initiation, suggesting an approach that can be adapted for future claims-based studies.

Excess prevalence of preexisting chronic conditions in older adults with incident epilepsy

OBJECTIVE

Prior studies have examined chronic conditions in older adults with prevalent epilepsy, but rarely among those with incident epilepsy. Identifying the chronic conditions with which older adults present at epilepsy incidence assists with the evaluation of disease burden in this patient population and informs coordinated care development. The aim of this study was to identify preexisting chronic conditions with excess prevalence in older adults with incident epilepsy compared to those without.

METHODS

Using a random sample of 4 999 999 fee-for-service Medicare beneficiaries aged >65 years, we conducted a retrospective cohort study of epilepsy incidence in 2019. Non-Hispanic Black and Hispanic beneficiaries were oversampled. We identified preexisting chronic conditions from the 2016-2018 Medicare Beneficiary Summary Files and compared chronic condition prevalence between Medicare beneficiaries with and without incident epilepsy in 2019. We characterized variations in preexisting excess chronic condition prevalence by age, sex, and race/ethnicity, adjusting for the racial/ethnic oversampling.

RESULTS

We observed excess prevalence of most preexisting chronic conditions in beneficiaries with incident epilepsy (n = 20 545, weighted n = 19 631). For stroke, for example, the adjusted prevalence rate ratio (APRR) was 4.82 (99% CI:4.60, 5.04), meaning that, compared to those without epilepsy, beneficiaries with incident epilepsy in 2019 had 4.82 times the stroke prevalence. Similarly, beneficiaries with incident epilepsy had a higher prevalence rate for preexisting neurological conditions (APRR = 3.17, 99% CI = 3.08-3.27), substance use disorders (APRR = 3.00, 99% CI = 2.81-3.19), and psychiatric disorders (APRR = 1.98, 99% CI = 1.94-2.01). For most documented chronic conditions, excess prevalence among beneficiaries with incident epilepsy in 2019 was larger for younger age groups compared to older age groups, and for Hispanic beneficiaries compared to both non-Hispanic White and non-Hispanic Black beneficiaries.

SIGNIFICANCE

Compared to epilepsy-free Medicare beneficiaries, those with incident epilepsy in 2019 had a higher prevalence of most preexisting chronic conditions. Our findings highlight the importance of health promotion and prevention, multidisciplinary care, and elucidating shared pathophysiology to identify opportunities for prevention.

Home Health Quality among Hospitalized Older Adults with Alzheimer's Disease and Related Dementia: Association with Race/Ethnicity and Dual Eligibility before and during the COVID Pandemic

OBJECTIVES

During the COVID-19 pandemic, home health agencies (HHAs) discharges following acute hospitalizations increased. This study examined whether racial and ethnic minoritized and socioeconomically disadvantaged patients (ie, Medicare-Medicaid dual-eligible) were differentially discharged to below-average quality HHAs before and during the COVID-19 pandemic. We focused on post-acute patients with Alzheimer's disease and related dementias (ADRD), who are generally frail and have high care needs.

DESIGN

Cohort study.

SETTING AND PARTICIPANTS

We linked 2019 to 2021 Medicare data with Area Deprivation Index (ADI), Home Health Compare, and COVID-19 infection data. We included Medicare beneficiaries with ADRD who were hospitalized for non-COVID-19 conditions and discharged to HHAs between January 2019 and November 2021. The final analytical sample included 426,766 qualified hospitalization events.

METHODS

The outcome variable was whether a patient received care from a below-average quality HHA, defined by an average Quality of Patient Care Star Rating lower than 3.0. Key independent variables included individual race, ethnicity, and Medicare-Medicaid dual status. Linear probability models with county fixed effects were estimated, sequentially adjusting for the individual- and community-level covariates. Sensitivity analysis using various definitions of below-average quality HHAs was conducted.

RESULTS

Before the pandemic, Black and Hispanic individuals had significantly higher probabilities of discharge to below-average quality HHAs compared with white individuals (3.4 and 3.9 percentage points, respectively). Dual-eligible individuals were also 2.5 percentage points more likely to be discharged to below-average quality HHAs. During the pandemic, disparities in being discharged to below-average quality HHAs persisted among racial and ethnic minoritized patients and increased among duals. Findings were consistent with and without adjusting for individual covariates and across different definitions of below-average quality HHA.

CONCLUSIONS AND IMPLICATIONS

Persistent disparities were observed in being discharged to below-average quality HHAs by race, ethnicity, and dual status. Further research is needed to identify factors contributing to these ongoing inequalities.