Racial variation in quality of care among Medicare+Choice enrollees

Patient perspectives for improving treatment initiation for new episodes of depression in historically minoritized racial and ethnic groups

OBJECTIVE

Depression is one of the costliest and most prevalent health conditions in the U.S. with 21 million adults having experienced at least one major depressive episode. Despite the availability of evidence-based treatments for depression, a large proportion of people with new diagnoses fail to initiate formal mental health treatment. Although individuals across all racial and ethnic groups fail to initiate treatment for depression, historically minoritized racial/ethnic groups are at even greater risk.

METHOD

Thirty-four participants representing historically underserved racial and ethnic populations from two large health care systems in the U.S. participated in qualitative interviews or focus group to identify factors that impede and facilitate depression treatment initiation in primary care settings.

RESULTS

Participants identified individual and systemic barriers and facilitators of treatment initiation for depression and suggested several ideas for increasing treatment engagement (i.e., increased communication and education from providers, community events, information on social media).

CONCLUSION

Novel interventions are needed to improve treatment initiation following initial diagnosis of depression in primary care settings. Findings from this study offer suggestions for improving treatment initiation in traditionally underserved communities.

Racial and ethnic disparities in access to and enrollment in high-quality Medicare Advantage plans

OBJECTIVE

Racial and ethnic minority enrollees in Medicare Advantage (MA) plans tend to be in lower-quality plans, measured by a 5-star quality rating system. We examine whether differential access to high-rated plans was associated with this differential enrollment in high-rated plans by race and ethnicity among MA enrollees.

DATA SOURCES

The Medicare Master Beneficiary Summary File and MA Landscape File for 2016.

STUDY DESIGN

We first examined county-level MA plan offerings by race and ethnicity. We then examined the association of racial and ethnic differences in enrollment by star rating by controlling for the following different sets of covariates: (1) individual-level characteristics only, and (2) individual-level characteristics and county-level MA plan offerings.

DATA COLLECTION/EXTRACTION METHODS

Not applicable PRINCIPAL FINDINGS: Racial and ethnic minority enrollees had, on average, more MA plans available in their counties of residence compared to White enrollees (16.1, 20.8, 20.2, vs. 15.1 for Black, Asian/Pacific Islander, Hispanic, and White enrollees), but had fewer number of high-rated plans (4-star plans or higher) and/or more number of low-rated plans (3.5-star plans or lower). While racial and ethnic minority enrollees had lower enrollment in 4-4.5 star plans than White enrollees, this difference substantially decreased after accounting for county-level MA plan offerings (-9.1 to -0.5 percentage points for Black enrollees, -15.9 to -5.0 percentage points for Asian/Pacific Islander enrollees, and -12.7 to 0.6 percentage points for Hispanic enrollees). Results for Black enrollees were notable as the racial difference reversed when we limited the analysis to those who live in counties that offer a 5-star plan. After accounting for county-level MA plan offerings, Black enrollees had 3.2 percentage points higher enrollment in 5-star plans than White enrollees.

CONCLUSIONS

Differences in enrollment in high-rated MA plans by race and ethnicity may be explained by limited access and not by individual characteristics or enrollment decisions.

Association of Medicare Advantage Star Ratings With Racial and Ethnic Disparities in Hospitalizations for Ambulatory Care Sensitive Conditions

BACKGROUND

Enrollment in high-quality Medicare Advantage (MA) plans, measured by a 5-star quality rating system, was lower among racial and ethnic minority enrollees than White enrollees partly due to fewer high-quality plans available in their counties of residence. This may contribute to racial and ethnic disparities in ambulatory care sensitive condition (ACSC) hospitalizations.

OBJECTIVE

We examined whether there were racial and ethnic disparities in ACSC hospitalizations among MA enrollees overall and by star rating.

METHODS

Using the Medicare enrollment and claims data for 2016, we identified White, Black, Hispanic, and Asian/Pacific Islander enrollees in MA plans. We estimated racial and ethnic disparities in ACSC hospitalizations (per 10,000 enrollees) overall and by star rating.

RESULTS

We found that the adjusted rates of ACSC hospitalizations were significantly higher among Black enrollees than White enrollees overall [39.4 (95% confidence interval: 36.3-42.5)]. However, no significant disparities were found among Hispanic and Asian/Pacific Islander enrollees. The adjusted rates of ACSC hospitalizations were higher in lower-rated plans than higher-rated plans in all racial and ethnic groups. The significant disparities in ACSC hospitalizations by star rating were the most pronounced between White and Black enrollees. We found suggestive evidence that enrollment in lower-rated plans was associated with higher disparities in ACSC hospitalizations between White and Black enrollees.

CONCLUSIONS

Substantial disparities in ACSC hospitalizations exist between White and Black enrollees in MA plans, especially for lower-rated plans. Policies aimed at reducing racial disparities in ACSC hospitalizations could include improving access to high-rated plans.

Disparities in all-cause mortality with potentially inappropriate medication use: Analysis of the Reasons for Geographic and Racial Differences in Stroke study

OBJECTIVES

Health disparities across different socioeconomic subgroups have been reported in previous studies. Mortality with potentially inappropriate medication (PIM) use may be subject to similar disparities. We aimed to assess the association between PIM use and all-cause mortality and the effect of disparity parameters (sex, race, income, education, and location of residence) on this relationship.

METHODS

This longitudinal cohort study included 26,399 U.S. adults aged 45 years and older from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, of which 13,475 participants were aged 65 years and older (recruited 2003-2007). PIM use and drug-drug interactions (DDIs) were identified through the 2015 Beers Criteria and a clinically significant DDIs list by the American Family Physicians, respectively. Cox regression was used to assess disparities in mortality with PIM use, iteratively adjusting for disparity parameters and other covariates. The full models included interaction terms between PIM use and other covariates. A similar method was used for the analyses of disparities in mortality with DDIs.

RESULTS

Approximately 87% of older adults used at least 1 drug listed in the Beers Criteria, and 3.8% of all participants used 2 or more drugs with DDIs. In the adjusted analysis, an increased risk of mortality was observed among whites with PIM use (hazard ratio [HR] = 1.27 [95% CI 1.10-1.47]). The higher mortality rate was observed among blacks without PIM use (1.34 [1.09-1.65]). Lower income and education were independent predictors for higher mortality.

CONCLUSION

Racial differences in all-cause mortality with PIM use were observed. Further research is needed to better understand the contributing factors of such disparities to develop appropriate interventions.

The association between Asian patient race/ethnicity and lower satisfaction scores

BACKGROUND

Patient satisfaction is increasingly being used to assess, and financially reward, provider performance. Previous studies suggest that race/ethnicity (R/E) may impact satisfaction, yet few practices adjust for patient R/E. The objective of this study is to examine R/E differences in patient satisfaction ratings and how these differences impact provider rankings.

METHODS

Patient satisfaction survey data linked to electronic health records from two large outpatient centers in northern California - a non-profit organization of community-based clinics (Site A) and an academic medical center (Site B) - was collected and analyzed. Participants consisted of adult patients who received outpatient care at Site A from December 2010 to November 2014 and Site B from March 2013 to August 2014, and completed Press-Ganey Medical Practice Survey questionnaires (N = 216,392 (Site A) and 30,690 (Site B)). Self-reported non-Hispanic white (NHW), Black, Latino, and Asian patients were studied. For six questions each representing a survey subdomain, favorable ratings were defined as top-box ("very good") compared to all other categories ("very poor," "poor," "fair," and "good"). Using multivariable logistic regression with provider random effects, we assessed whether the likelihood of giving favorable ratings differed by patient R/E, adjusting for patient age and sex.

RESULTS

Asian, younger and female patients provided less favorable ratings than other R/E, older and male patients. After adjustment, Asian patients were less likely than NHW patients to provide top-box ratings to the overall assessment question "likelihood of recommending this practice to others" (Site A: Asian predicted probability (PP) 0.680, 95% confidence interval (CI): 0.675-0.685 compared to NHW PP 0.820, 95% CI: 0.818-0.822; Site B: Asian PP 0.734, 95% CI: 0.733-0.736 compared to NHW PP 0.859, 95% CI: 0.859-0.859). The effect sizes for Asian R/E were greater than the effect sizes for older age and female sex. An absolute 3% decrease in mean composite score between providers serving different percentages of Asian patients translated to an absolute 40% drop in national ranking.

CONCLUSIONS

Patient satisfaction scores may need to be adjusted for patient R/E, particularly for providers caring for high panel percentages of Asian patients.

Association of Race and Major Adverse Cardiac Events (MACE): The Atherosclerosis Risk in Communities (ARIC) Cohort

Background and Aims

To evaluate the association of self-reported race with major adverse cardiac events (MACE) and modification of this association by paraoxonase gene (PON1, PON2, and PON3) single nucleotide polymorphisms (SNPs).

Methods

Included in this longitudinal study were 12,770 black or white participants from the Atherosclerosis Risk in Communities (ARIC) cohort who completed a baseline visit (1987–1989) with PON genotyping. Demographic, behavioral, and health information was obtained at baseline. MACE was defined as first occurrence of myocardial infarction, stroke, or CHD-related death through 2004. Cox proportional hazards regression was used to evaluate the association between race and MACE after adjustment for age, gender, and other demographic and cardiovascular risk factors such as diabetes and hypertension. Modification of the association between PON SNPs and MACE was also assessed.

Results

Blacks comprised 24.6% of the ARIC cohort; overall, 14.0% of participants developed MACE. Compared with whites, blacks had 1.24 times greater hazard of MACE (OR = 1.24,95%CI = 1.10,1.39) than whites after adjusting for age, gender, BMI, cigarette and alcohol use, educational and marital status, and aspirin use. This association became nonsignificant after further adjustment for high cholesterol, diabetes, and hypertension. None of the evaluated SNPs met the significance level (p < 0.001) after Bonferroni correction for multiple comparisons.

Conclusions

No association between race and MACE was identified after adjusting for high cholesterol, diabetes, and hypertension, suggesting that comorbidities are major determinants of MACE; medical intervention with focus on lifestyle and health management could ameliorate the development of MACE. Further studies are needed to confirm this observation.

Health Disparities and Sepsis: a Systematic Review and Meta-Analysis on the Influence of Race on Sepsis-Related Mortality

RATIONALE

Racial disparities in sepsis outcomes have been previously reported. However, recently, there have been inconsistencies in identifying which socioeconomic variables, such as race, account for these disparities. The objective of this study was to perform a systematic review in order to examine the impact of race on sepsis-attributable mortality.

METHODS

Systematic searches for English-language articles identified through MEDLINE, EBSCOhost, PubMed, ERIC, and Cochrane Library databases from 1960 to 1 February 2017. Included studies examined sepsis outcomes in the context of sepsis incidence and/or mortality. Two investigators independently extracted data and assessed study quality. The meta-analysis was performed in accordance with the Cochrane Collaboration guidelines.

RESULTS

Twenty-one studies adhered to the predefined selection criteria and were included in the review. Of the 21 studies, we pooled data from 6 studies comparing African American/Black race as a risk factor for sepsis-related mortality disparities (reference group being Caucasian/White). From the meta-analysis on these six studies, African American/Black race was found to have no statistical significant relationship with sepsis-related mortality (odds ratio 1.20, 95% CI, 0.81 to 1.77). Similar results were found for other races (Native Americans, Asians) and ethnicities (Hispanic/Latinos).

CONCLUSION

On the basis of available evidence from a limited number of observation retrospective studies, race alone cannot fully explain sepsis-related disparities, especially sepsis-attributable mortality.

Use of Welcome to Medicare Visits Among Older Adults Following the Affordable Care Act

INTRODUCTION

To encourage greater utilization of preventive services among Medicare beneficiaries, the 2010 Affordable Care Act waived coinsurance for the Welcome to Medicare visit, making this benefit free starting in 2011. The objective of this study was to determine the impact of the Affordable Care Act on Welcome to Medicare visit utilization.

METHODS

A 5% sample of newly enrolled fee-for-service Medicare beneficiaries for 2005-2016 was used to estimate changes in Welcome to Medicare visit use over time. An interrupted time series model examined whether Welcome to Medicare visits increased significantly after 2011, controlling for pre-intervention trends and other autocorrelation.

RESULTS

Annual Welcome to Medicare visit rates began at 1.4% in 2005 and increased to 12.3% by 2016. The quarterly Welcome to Medicare visit rate, which was almost 1% at baseline, was increasing by 0.06% before the 2011 Affordable Care Act provision (p<0.001). Immediately following the 2011 Affordable Care Act provision, the rate increased by about 1% in the first quarter of 2011 (intercept, p<0.001), followed by an increase of 0.13% every subsequent quarter (slope, p<0.001). This general trend was observed in subgroup analyses, although this trend varied by subgroups where the pre-Affordable Care Act trends of lower utilization persisted over time for non-whites and improved less quickly for men, regions other than Northeast, and beneficiaries without any supplemental insurance.

CONCLUSIONS

The Affordable Care Act, and perhaps the removal of cost sharing, was associated with increased use of the Welcome to Medicare visit; however, even with the increased use, there is room for improvement.

Defining 'quality' from the patient's perspective: findings from focus groups with Medicaid beneficiaries and implications for public reporting

BACKGROUND

With an increased emphasis on patient-centred outcomes and research, investigators seek to understand aspects of health care that are most important to patients. Such information is essential for developing report cards that present health-care quality information for consumers, which many states are adopting as a strategy to promote consumer choice.

OBJECTIVE

This study examined the processes that women in Medicaid follow for selecting health plans and explored their definitions of 'good' and 'poor' quality health care.

DESIGN

We conducted focus groups with Medicaid beneficiaries in four Texas communities, using quota sampling to ensure representation of different racial/ethnic, eligibility and geographic groups.

RESULTS

We conducted 22 focus groups with 102 participants between October 2012 and January 2013. In a free-list exercise, 'doctors' represented the most important aspect of health care to participants, followed by cost, attention, coverage and respect. Discussions of health-care quality revealed an even mix of structural factors (e.g. timeliness) and interpersonal factors (e.g. communication), although few differences were observed by beneficiary characteristics. Participants linked themes in their overall framing of 'quality' - revealing processes of care that affect health outcomes (e.g. discontinuity of care resulting from poor communication with providers) and which were often mediated by advocate providers who assisted patients experiencing barriers to services.

DISCUSSION AND CONCLUSIONS

Findings support other studies that highlight the importance of the patient-provider relationship. Patient-centred definitions of health-care quality can complement predominant provider-centred conceptual frameworks and better inform initiatives for public reporting of quality measures in these populations.

Geographic Variation in Quality of Care for Commercially Insured Patients

BACKGROUND

Extensive evidence documents geographic variation in spending, but limited research assesses geographic variation in quality, particularly among commercially insured enrollees.

OBJECTIVE

To measure geographic variation in quality measures, correlation among measures, and correlation between measures and spending for commercially insured enrollees.

DATA SOURCE

Administrative claims from the 2007-2009 Truven MarketScan database.

METHODS

We calculated variation in, and correlations among, 10 quality measures across 306 Hospital Referral Regions (HRRs), adjusting for beneficiary traits and sample size differences. Further, we created a quality index and correlated it with spending.

RESULTS

The coefficient of variation of HRR-level performance ranged from 0.04 to 0.38. Correlations among quality measures generally ranged from 0.2 to 0.5. Quality was modestly positively related to spending.

CONCLUSION

Quality varied across HRRs and there was only a modest geographic "quality footprint."

Identifying the Transgender Population in the Medicare Program

Purpose: To identify and describe the transgender population in the Medicare program using administrative data. Methods: Using a combination of International Classification of Diseases ninth edition (ICD-9) codes relating to transsexualism and gender identity disorder, we analyzed 100% of the 2013 Centers for Medicare & Medicaid Services (CMS) Medicare Fee-For-Service (FFS) "final action" claims from both institutional and noninstitutional providers (∼1 billion claims) to identify individuals who may be transgender Medicare beneficiaries. To confirm, we developed and applied a multistage validation process. Results: Four thousand ninety-eight transgender beneficiaries were identified, of which ∼90% had confirmatory diagnoses, billing codes, or evidence of a hormone prescription. In general, the racial, ethnic, and geographic distribution of the Medicare transgender population tends to reflect the broader Medicare population. However, age, original entitlement status, and disease burden of the transgender population appear substantially different. Conclusions: Using a variety of claims information, ranging from claims history to additional diagnoses, billing modifiers, and hormone prescriptions, we demonstrate that administrative data provide a valuable resource for identifying a lower bound of the Medicare transgender population. In addition, we provide a baseline description of the diversity and disease burden of the population and a framework for future research.

Measurement equivalence of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Medicare survey items between Whites and Asians

PURPOSE

Asians report worse experiences with care than Whites. This could be due to true differences in care received, expectations about care, or survey response styles. We examined responses to the Consumer Assessment of Healthcare Providers and Systems (CAHPS^®) Medicare survey items by Whites and Asians, controlling for underlying level on the CAHPS constructs.

METHODS

We conducted multiple group analyses to evaluate measurement equivalence of CAHPS Medicare survey data between White and Asian Medicare beneficiaries for CAHPS reporting composites (communication with personal doctor, access to care, plan customer service) and global ratings of care using pooled data from 2007 to 2011. Responses were obtained from 1,326,410 non-Hispanic Whites and 40,672 non-Hispanic Asians (hereafter referred to as Whites and Asians). The median age for Whites was 70, with 24 % 80 or older, and 70 for Asians, with 23 % 80 or older. Fifty-eight percent of Whites and 56 % of Asians were female.

RESULTS

A model without group-specific estimates fit the data as well as a model that included 12 group-specific estimates (7 factor loadings, 3 measured variable errors, and 2 item intercepts): Comparative Fit Index = 0.947 and 0.948; root-mean-square error of approximation = 0.052 and 0.052, respectively). Differences in latent CAHPS score means between Whites and Hispanics estimated from the two models were similar, differing by 0.053 SD or less.

CONCLUSIONS

This study provides support for measurement equivalence of the CAHPS Medicare survey composites (communication, access, customer service) and global ratings between White and Asian respondents, supporting comparisons of care experiences between the two groups.

Differences in Pain Coping Between Black and White Americans: A Meta-Analysis

Compared with white individuals, black individuals experience greater pain across clinical and experimental modalities. These race differences may be due to differences in pain-related coping. Several studies examined the relationship between race and pain coping; however, no meta-analytic review has summarized this relationship or attempted to account for differences across studies. The goal of this meta-analytic review was to quantify race differences in the overall use of pain coping strategies as well as specific coping strategies. Relevant studies were identified using electronic databases, an ancestry search, and by contacting authors for unpublished data. Of 150 studies identified, 19 met inclusion criteria, resulting in 6,489 participants and 123 effect sizes. All of the included studies were conducted in the United States. Mean effect sizes were calculated using a random effects model. Compared with white individuals, black individuals used pain coping strategies more frequently overall (standardized mean difference [d] = .25, P < .01), with the largest differences observed for praying (d = .70) and catastrophizing (d = .40). White individuals engaged in task persistence more than black individuals (d = -.28). These results suggest that black individuals use coping strategies more frequently, specifically strategies associated with poorer pain outcomes. Future research should examine the extent to which the use of these strategies mediates race differences in the pain experience.

PERSPECTIVE

Results of this meta-analysis examining race differences in pain-related coping indicate that, compared with white individuals, black individuals use coping strategies more frequently, specifically those involving praying and catastrophizing. These differences in coping may help to explain race differences in the pain experience.

Less Use of Extreme Response Options by Asians to Standardized Care Scenarios May Explain Some Racial/Ethnic Differences in CAHPS Scores

BACKGROUND

Asian Americans (hereafter "Asians") generally report worse experiences with care than non-Latino whites (hereafter "whites"), which may reflect differential use of response scales. Past studies indicate that Asians exhibit lower Extreme Response Tendency (ERT)-they less frequently use responses at extreme ends of the scale than whites.

OBJECTIVE

To explore whether lower ERT is observed for Asians than whites in response to standardized vignettes depicting patient experiences of care and whether ERT might in part explain Asians reporting worse care than whites.

PROCEDURE

A representative US sample (n=575 Asian; n=505 white) was presented with 5 written vignettes describing doctor-patient encounters with differing levels of physician responsiveness. Respondents evaluated the encounters using modified CAHPS communication questions.

RESULTS

Case-mix-adjusted repeated-measures multivariate models show that Asians provided more positive responses than whites to several vignettes with less-responsive physicians but less positive responses than whites for the vignette with the most physician responsiveness (P<0.01 for each). While all respondents provided more positive ratings for vignettes with greater physician responsiveness, the increase was 15% less for Asian than white respondents.

CONCLUSIONS

Asians exhibit lower ERT than whites in response to standardized scenarios. Because CAHPS reponses are predominantly near the positive end of the scale and the most responsive scenario is most typical of the score observed in real-world settings, lower ERT in Asians may partially explain observations of lower observed mean CAHPS scores for Asians in real-world settings. Case-mix adjustment for Asian race/ethnicity or its correlates may improve quality of care measurement.

Association of EMR Adoption with Minority Health Care Outcome Disparities in US Hospitals

Objectives

Disparities in healthcare among minority groups can result in disparate treatments for similar severities of symptoms, unequal access to medical care, and a wide deviation in health outcomes. Such racial disparities may be reduced via use of an Electronic Medical Record (EMR) system. However, there has been little research investigating the impact of EMR systems on the disparities in health outcomes among minority groups.

Methods

This study examined the impact of EMR systems on the following four outcomes of black patients: length of stay, inpatient mortality rate, 30-day mortality rate, and 30-day readmission rate, using patient and hospital data from the Medicare Provider Analysis and Review and the Healthcare Information and Management Systems Society between 2000 and 2007. The difference-in-difference research method was employed with a generalized linear model to examine the association of EMR adoption on health outcomes for minority patients while controlling for patient and hospital characteristics.

Results

We examined the association between EMR adoption and the outcomes of minority patients, specifically black patients. However, after controlling for patient and hospital characteristics we could not find any significant changes in the four health outcomes of minority patients before and after EMR implementation.

Conclusions

EMR systems have been reported to support better coordinated care, thus encouraging appropriate treatment for minority patients by removing potential sources of bias from providers. Also, EMR systems may improve the quality of care provided to patients via increased responsiveness to care processes that are required to be more time-sensitive and through improved communication. However, we did not find any significant benefit for minority groups after EMR adoption.

The impact of health information technology on disparity of process of care

Introduction

Disparities in the quality of health care and treatment among racial or ethnic groups can result from unequal access to medical care, disparate treatments for similar severities of symptoms, and wide divergence in general health status among individuals. Such disparities may be eliminated through better use of health information technology (IT). Investment in health IT could foster better coordinated care, improve guideline compliance, and reduce the likelihood of redundant testing, thereby encouraging more equitable treatment for underprivileged populations. However, there is little research exploring the impact of health IT investment on disparities of process of care.

Methodology

This study examines the impact of health IT investment on waiting times – from admission to the date of first principle procedure – among different racial and ethnic groups, using patient and hospital data for the state of California collected from 2001 to 2007. The final sample includes 14,056,930 patients admitted with medical diseases to 316 unique, acute-care hospitals over a seven-year period. The linear random intercept and slope model was employed to examine the impacts of health IT investment on waiting time, while controlling for patient, disease, and hospital characteristics.

Results

Greater health IT investment was associated with shorter waiting times, and the reduction in waiting times was greater for non-White than for White patients. This indicates that minority populations could benefit from health IT investment with regard to process of care.

Conclusion

Investments in health IT may reduce disparities in process of care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12939-015-0161-3) contains supplementary material, which is available to authorized users.

Race and referral to diabetes education in primary care patients with prediabetes and diabetes

PURPOSE

The purpose of the study was to determine whether there are any race-related disparities in the prevalence of provisions for diabetes education in primary care clinics for patients with diabetes and prediabetes.

METHODS

A retrospective cross-sectional study of 3967 patients aged 14 to >89 years with prediabetes and diabetes. Medical record data from patient encounters within primary care clinics at a large academic medical health system between July 1, 2008, and July 31, 2013, were used to determine rates of referral for diabetes education by race. Multivariate logistic regression models were used to assess associations between race and referral to diabetes education. Separate regression models were computed for patients who were prediabetic and diabetic. Adjusted models included age, sex, A1C, health care utilization, smoking, and diagnosis for depression, hyperlipidemia, hypertension, vascular disease, and obesity.

RESULTS

Compared to that of white patients, a significantly higher prevalence of African American patients with prediabetes were referred to diabetes education, and this association was also observed in patients with diabetes. In fully adjusted models, white patients with prediabetes were significantly less likely to be referred.

CONCLUSIONS

Being African American independently increased the likelihood of referral for diabetes education in patients with prediabetes and patients with diabetes. After adjusting for patient comorbidities and risk factors, this association remained significant for patients with prediabetes. Additional research is needed to determine if provider beliefs and attitudes regarding race and diabetes education account for this association.

Cardiopulmonary resuscitation among mechanically ventilated patients

PURPOSE

To evaluate the outcomes, including long-term survival, after cardiopulmonary resuscitation (CPR) in mechanically ventilated patients.

METHODS

We analyzed Medicare data from 1994 to 2005 to identify beneficiaries who underwent in-hospital CPR. We then identified a subgroup receiving CPR one or more days after mechanical ventilation was initiated [defined by ICD-9 procedure code for intubation (96.04) or mechanical ventilation (96.7x) one or more days prior to procedure code for CPR (99.60 or 99.63)].

RESULTS

We identified 471,962 patients who received in-hospital CPR with an overall survival to hospital discharge of 18.4 % [95 % confidence interval (CI) 18.3-18.5 %]. Of those, 42,163 received CPR one or more days after mechanical ventilation initiation. Survival to hospital discharge after CPR in ventilated patients was 10.1 % (95 % CI 9.8-10.4 %), compared to 19.2 % (95 % CI 19.1-19.3 %) in non-ventilated patients (p < 0.001). Among this group, older age, race other than white, higher burden of chronic illness, and admission from a nursing facility were associated with decreased survival in multivariable analyses. Among all CPR recipients, those who were ventilated had 52 % lower odds of survival (OR 0.48, 95 % CI 0.46-0.49, p < 0.001). Median long-term survival in ventilated patients receiving CPR who survived to hospital discharge was 6.0 months (95 % CI 5.3-6.8 months), compared to 19.0 months (95 % CI 18.6-19.5 months) among the non-ventilated survivors (p < 0.001 by logrank test). Of all patients receiving CPR while ventilated, only 4.1 % were alive at 1 year.

CONCLUSIONS

Survival after in-hospital CPR is decreased among ventilated patients compared to those who are not ventilated. This information is important for clinicians, patients, and family members when discussing CPR in critically ill patients.

Healthcare disparities in critical illness

OBJECTIVE

To summarize the current literature on racial and gender disparities in critical care and the mechanisms underlying these disparities in the course of acute critical illness.

DATA SOURCES

MEDLINE search on the published literature addressing racial, ethnic, or gender disparities in acute critical illness, such as sepsis, acute lung injury, pneumonia, venous thromboembolism, and cardiac arrest.

STUDY SELECTION

Clinical studies that evaluated general critically ill patient populations in the United States as well as specific critical care conditions were reviewed with a focus on studies evaluating factors and contributors to health disparities.

DATA EXTRACTION

Study findings are presented according to their association with the prevalence, clinical presentation, management, and outcomes in acute critical illness.

DATA SYNTHESIS

This review presents potential contributors for racial and gender disparities related to genetic susceptibility, comorbidities, preventive health services, socioeconomic factors, cultural differences, and access to care. The data are organized along the course of acute critical illness.

CONCLUSIONS

The literature to date shows that disparities in critical care are most likely multifactorial involving individual, community, and hospital-level factors at several points in the continuum of acute critical illness. The data presented identify potential targets as interventions to reduce disparities in critical care and future avenues for research.

Does the racial/ethnic composition of Medicare Advantage plans reflect their areas of operation?

OBJECTIVE

To assess the extent to which the racial/ethnic composition of Medicare Advantage (MA) plans reflects the composition of their areas of operation, given the potential incentives created by the Centers for Medicare & Medicaid Services' Quality Bonus Payments for such plans to avoid enrolling racial/ethnic minority beneficiaries.

DATA SOURCES/STUDY SETTING

2009 Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) survey and administrative data from the Medicare Enrollment Database.

DATA COLLECTION/EXTRACTION METHODS

We defined each plan's area of operation as all counties in which it had MA enrollees, and we created a matrix of race/ethnicity by plan by county of residence to assess the racial/ethnic distribution of each plan's enrollees in comparison with the racial/ethnic composition of MA beneficiaries in its operational area.

PRINCIPAL FINDINGS

There is little evidence that health plans are selectively underenrolling blacks, Latinos, or Asians to a substantial degree. A small but potentially important subset of plans disproportionately serves minority beneficiaries.

CONCLUSIONS

These findings provide a baseline profile that will enable crucial ongoing monitoring to assess how the implementation of Quality Bonus Payments may affect MA plan coverage of minority populations.

Impact of timing of adjuvant chemotherapy initiation and completion after surgery on racial disparities in survival among women with breast cancer

While large differences by race/ethnicity in breast cancer survival are well established, it is unknown whether differences in quality of chemotherapy delivered explain the racial/ethnic disparities in survival among black, Hispanic, Asian, and white women with breast cancer. We evaluated factors associated with time to initiation of adjuvant chemotherapy and chemotherapy completion and examined outcomes data among women with breast cancer. Patients who initiated chemotherapy later than 3 months after surgery were 1.8 times more likely to die of breast cancer (95 % CI 1.3-2.5) compared with those who initiated chemotherapy less than a month after surgery, even after controlling for known confounders or controlling for race/ethnicity. Women who completed chemotherapy had significantly higher survival compared with those who have not completed chemotherapy. Despite correcting for chemotherapy initiation and completion and known predictors of outcome, African American women still had worse disease-specific survival than their Caucasian counterparts. While a complete and timely adjuvant treatment among various ethnic populations would help to reduce racial disparities in survival, there are still other factors to be identified that may explain the remaining differences in survival between ethnic women with breast cancer.

The validity of race and ethnicity in enrollment data for Medicare beneficiaries

OBJECTIVE

To assess the validity of race/ethnicity in Medicare databases for studies of racial/ethnic disparities.

DATA SOURCES

The 2010 Medicare Consumer Assessments of Healthcare Providers and Systems (CAHPS(®)) survey was linked to Medicare enrollment data and local area characteristics from the 2000 Census.

STUDY DESIGN

Race/ethnicity was cross-tabulated for CAHPS and Medicare data. Within each self-reported category, demographic, geographic, health, and health care variables were compared between those that were and were not similarly identified in Medicare data.

DATA COLLECTION METHODS

The Medicare CAHPS survey included 343,658 responses from elderly participants (60 percent response rate). Data were weighted for sampling and nonresponse to be representative of the national population of elderly Medicare beneficiaries.

PRINCIPAL FINDINGS

Self-reported Hispanics, Asians, Pacific Islanders, and American Indians were underidentified in Medicare enrollment data. Individuals in these groups who were identified in Medicare data tended to be more strongly identified with their group, poorer, and in worse health and to report worse health care experiences than those who were not so identified.

CONCLUSIONS

Self-reported members of racial and ethnic groups other than Whites and Blacks who are identified in Medicare data differ substantially from those who are not so identified. These differences should be considered in assessments of disparities in health and health care among Medicare beneficiaries.

Variability in case-mix adjusted in-hospital cardiac arrest rates

BACKGROUND

It is unknown how in-hospital cardiac arrest (IHCA) rates vary across hospitals and predictors of variability.

OBJECTIVES

Measure variability in IHCA across hospitals and determine if hospital-level factors predict differences in case-mix adjusted event rates.

RESEARCH DESIGN

Get with the Guidelines Resuscitation (GWTG-R) (n=433 hospitals) was used to identify IHCA events between 2003 and 2007. The American Hospital Association survey, Medicare, and US Census were used to obtain detailed information about GWTG-R hospitals.

PARTICIPANTS

Adult patients with IHCA.

MEASURES

Case-mix-adjusted predicted IHCA rates were calculated for each hospital and variability across hospitals was compared. A regression model was used to predict case-mix adjusted event rates using hospital measures of volume, nurse-to-bed ratio, percent intensive care unit beds, palliative care services, urban designation, volume of black patients, income, trauma designation, academic designation, cardiac surgery capability, and a patient risk score.

RESULTS

We evaluated 103,117 adult IHCAs at 433 US hospitals. The case-mix adjusted IHCA event rate was highly variable across hospitals, median 1/1000 bed days (interquartile range: 0.7 to 1.3 events/1000 bed days). In a multivariable regression model, case-mix adjusted IHCA event rates were highest in urban hospitals [rate ratio (RR), 1.1; 95% confidence interval (CI), 1.0-1.3; P=0.03] and hospitals with higher proportions of black patients (RR, 1.2; 95% CI, 1.0-1.3; P=0.01) and lower in larger hospitals (RR, 0.54; 95% CI, 0.45-0.66; P<0.0001).

CONCLUSIONS

Case-mix adjusted IHCA event rates varied considerably across hospitals. Several hospital factors associated with higher IHCA event rates were consistent with factors often linked with lower hospital quality of care.

Prevalence of nontuberculous mycobacterial lung disease in U.S. Medicare beneficiaries

RATIONALE

Pulmonary nontuberculous mycobacteria (PNTM) are an important cause of morbidity among older adults in the United States, but national prevalence estimates are lacking.

OBJECTIVES

To describe the prevalence and trends of PNTM disease among adults aged 65 years or older throughout the United States.

METHODS

A nationally representative 5% sample of Medicare Part B beneficiaries was analyzed from 1997 to 2007. Demographic and medical claims data were compiled and prevalence estimates for PNTM and selected comorbidities were calculated and trends over time evaluated. Logistic regression was used to identify demographic and geographic factors associated with PNTM.

MEASUREMENTS AND MAIN RESULTS

From 1997 to 2007, the annual prevalence significantly increased from 20 to 47 cases/100,000 persons, or 8.2% per year. The period prevalence was 112 cases/100,000 persons, although prevalence was twofold higher among Asians/Pacific Islanders than among whites (228 vs. 116 cases/100,000 persons). Western states had the highest period prevalence at 149 cases/100,000 persons, with Hawaii having the highest prevalence at 396 cases/100,000 persons, followed by southeastern states, which had a period prevalence of 131 cases/100,000 persons. PNTM cases had more comorbid conditions than noncases and were 40% more likely to die than noncases. Women were 1.4 times more likely to be a PNTM case than men. Relative to whites, Asians/Pacific Islanders were twice as likely to be a case, whereas blacks were half as likely.

CONCLUSIONS

The prevalence of PNTM is increasing across all regions of the United States and among both men and women. Significant racial/ethnic and geographic differences suggest important gene-environment interactions.

Variation in diabetes care quality among medicare advantage plans: understanding the role of case mix

This study investigates whether variation in Medicare Advantage plan performance on comprehensive diabetes care is explained by the case mix of plans. Using data on 513 Medicare Advantage plan-year observations for 2007 and 2008, the authors estimate multivariate regressions for 3 diabetes care quality measures: (1) hemoglobin screening, (2) low-density lipoprotein screening, and (3) retinal eye exam. Plan case mix is measured with the percentage of a plan's enrollees who have type 1 diabetes with and without comorbidities and the percentage of a plan's enrollees who have type 2 diabetes with and without comorbidities. Plans with a higher percentage of enrollees with type 1 diabetes with comorbidity and plans with a higher percentage of enrollees with type 2 diabetes without comorbidity have lower performance, on average. Finding evidence of a relationship between case mix and Healthcare Effectiveness Data and Information Set performance reinforces the argument for developing standardized risk adjustment or stratification methods in public reporting and pay-for-performance efforts.

Breast reconstructive surgery in medically underserved women with breast cancer: the role of patient-physician communication

BACKGROUND

Breast reconstructive surgery can improve mastectomy patients' emotional relationships and social functioning, but it may be underutilized in low-income, medically underserved women. This study assessed the impact of patient-physician communication on rates of breast reconstructive surgery in low-income breast cancer (BC) women receiving mastectomy.

METHODS

A cross-sectional, California statewide survey was conducted of women with income less than 200% of the Federal Poverty Level and receiving BC treatment through the Medicaid Breast and Cervical Cancer Treatment Program. A subset of 327 women with nonmetastatic disease who underwent mastectomy was identified. Logistic regression was used for data analysis. The chief dependent variable was receipt of or planned breast reconstructive surgery by patient report at 6 months after diagnosis; chief independent variables were physician interactive information giving and patient perceived self-efficacy in interacting with physicians.

RESULTS

Greater physician information giving about BC and its treatment and greater patient perceived self-efficacy positively predicted breast reconstructive surgery (OR=1.12, P=.04; OR=1.03, P=.01, respectively). The observed negative effects of language barriers and less acculturation among Latinas and lower education at the bivariate level were mitigated in multivariate modeling with the addition of the patient-physician communication and self-efficacy variables.

CONCLUSIONS

Empowering aspects of patient-physician communication and self-efficacy may overcome the negative effects of language barriers and less acculturation for Latinas, as well as of lower education generally, on receipt of or planned breast reconstructive surgery among low-income women with BC. Intervening with these aspects of communication could result in breast reconstructive surgery rates more consistent with the general population and in improved quality of life among this disadvantaged group.

Influence of patient race on physician prescribing decisions: a randomized on-line experiment

BACKGROUND

Prior research reports black patients have lower medication use for hypercholesterolemia, hypertension, and diabetes.

OBJECTIVE

To assess whether patient race influences physicians' prescribing.

DESIGN

Web-based survey including three clinical vignettes (hypercholesterolemia, hypertension, diabetes), with patient race (black, white) randomized across vignettes.

SUBJECTS

A total of 716 respondents from 5,141 eligible sampled primary care physicians (14% response rate).

INTERVENTIONS

None

MEASUREMENTS

Medication recommendation (any medication vs none, on-patent branded vs generic, and therapeutic class) and physicians' treatment adherence forecast (10-point Likert scale, 1-definitely not adhere, 10-definitely adhere).

RESULTS

Respondents randomized to view black patients (n = 371) and white patients (n = 345) recommend any medications at comparable rates for hypercholesterolemia (100.0% white vs 99.5% black, P = 0.50), hypertension (99.7% white vs 99.5% black, P = 1.00), and diabetes (99.7% white vs 99.7% black, P = 1.00). Patient race influenced medication class chosen in the hypertension vignette; respondents randomized to view black patients recommended calcium channel blockers more often (20.8% black vs 3.2% white) and angiotensin-converting enzyme inhibitors less often (47.4% black vs 62.6% white) (P < 0.001). Patient race did not influence medication class for hypercholesterolemia or diabetes. Respondents randomized to view black patients reported lower forecasted patient adherence for hypertension (P < 0.001, mean: 7.3 black vs 7.7 white) and diabetes (P = 0.05 mean: 7.4 black vs 7.6 white), but race had no meaningful influence on forecasted adherence for hypercholesterolemia (P = 0.15, mean: 7.2 black vs 7.3 white).

CONCLUSION

Racial differences in outpatient prescribing patterns for hypertension, hypercholesterolemia, and diabetes are likely attributable to factors other than prescribing decisions based on patient race.

Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly

BACKGROUND

It is unknown whether the rate of survival after in-hospital cardiopulmonary resuscitation (CPR) is improving and which characteristics of patients and hospitals predict survival.

METHODS

We examined fee-for-service Medicare data from 1992 through 2005 to identify beneficiaries 65 years of age or older who underwent CPR in U.S. hospitals. We examined temporal trends in the incidence of CPR and the rate of survival after CPR, as well as patient- and hospital-level predictors of survival to discharge.

RESULTS

We identified 433,985 patients who underwent in-hospital CPR; 18.3% of these patients (95% confidence interval [CI], 18.2 to 18.5) survived to discharge. The rate of survival did not change substantially during the period from 1992 through 2005. The overall incidence of CPR was 2.73 events per 1000 admissions; the incidence was higher among black and other nonwhite patients. The proportion of patients undergoing in-hospital CPR before death increased over time and was higher for nonwhite patients. The survival rate was lower among patients who were men, were older, had more coexisting illnesses, or were admitted from a skilled-nursing facility. The adjusted odds of survival for black patients were 23.6% lower than those for similar white patients (95% CI, 21.2 to 25.9). The association between race and survival was partially explained by hospital effects: black patients were more likely to undergo CPR in hospitals that have lower rates of post-CPR survival. Among patients surviving in-hospital CPR, the proportion of patients discharged home rather than to a health care facility decreased over time.

CONCLUSIONS

Survival after in-hospital CPR did not improve from 1992 through 2005. The proportion of in-hospital deaths preceded by CPR increased, whereas the proportion of survivors discharged home after undergoing CPR decreased. Black race was associated with higher rates of CPR but lower rates of survival after CPR.

The prevalence of erectile dysfunction in heart failure patients by race and ethnicity

Erectile dysfunction (ED) is a common problem in male patients with heart failure (HF). However, no study was found that estimates the prevalence of ED by US ethnic groups with HF. We conducted an observational, cross-sectional study of patients enrolled in a HF disease management program in two sites Louisiana (N=329; 178 white, 99 black) and Florida (N=52; Hispanic). All male patients with an ejection fraction <or=40% were included. The Sexual Health Inventory for Men was used to estimate the prevalence of ED. Overall prevalence of ED was 89% and ED severity did not vary by race/ethnic group. Race/ethnic group differences were found for age, New York Heart Association functional classification, and blood pressure. Hispanic patients had the lowest unadjusted and adjusted prevalence rate of ED (81, 85%) compared to Black (90, 95%) and White (91, 92%) patients. There is a high prevalence of ED in Hispanic, Black and White ethnic groups with HF.

How to engage the Latino or African American patient with benign prostatic hyperplasia: crossing socioeconomic and cultural barriers

Disparities based on race and ethnicity still exist in the US healthcare system. Such disparities are reflected in the diagnosis and treatment of benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) among African Americans and Latinos. The prevalence of risk factors for BPH and LUTS and symptom progression are higher in these populations, but treatment is less common. African American men and Latinos frequently have other serious comorbidities, such as cardiovascular disease, diabetes mellitus, and metabolic syndrome. Health plan constraints and variabilities, race/ethnicity, socioeconomic status, language, healthcare-seeking behaviors, and cultural beliefs and practices influence the treatment of BPH and LUTS, oftentimes resulting in unequal access to care or inferior quality of care. The provision of nondiscriminatory treatment poses a challenge to clinicians that can partially be addressed by improving the cultural competence of practitioners in minority communities. An awareness of the customs and healing traditions of African Americans and Latinos may also facilitate culturally appropriate care and improve outcomes, and the participation of clinicians in continuing education/professional development programs to increase knowledge about minority health issues is recommended. Conversely, improving the health literacy of African American and Latino patients with BPH and LUTS can help avoid ineffective nontraditional methods of treatment.

Primary-care clinician perceptions of racial disparities in diabetes care

BACKGROUND

Primary-care clinicians can play an important role in reducing racial disparities in diabetes care.

OBJECTIVE

The objective of the study is to determine the views of primary-care clinicians regarding racial disparities in diabetes care.

DESIGN

The design of the study is through a survey of primary-care clinicians (response rate = 86%).

PARTICIPANTS

The participants of the study were 115 physicians and 54 nurse practitioners and physician assistants within a multisite group practice in 2007.

MEASUREMENTS AND MAIN RESULTS

We identified sociodemographic characteristics of each clinician's diabetic patient panel. We fit multivariable logistic regression models to identify predictors of supporting the collection of data on patients' race and acknowledging the existence of racial disparities among patients personally treated. Among respondents, 79% supported the collection of data on patients' race. Whereas 88% acknowledged the existence of racial disparities in diabetes care within the U.S. health system, only 40% reported their presence among patients personally treated. Clinicians caring for greater than or equal to 50% minority patients were more likely to support collection of patient race data (adjusted odds ratio [OR] 9.0; 95% confidence interval [CI] 1.2-65.0) and report the presence of racial disparities within their patient panel (adjusted OR 12.0; 95% CI 2.5-57.7). Clinicians were more likely to perceive patient factors than physician or health system factors as mediators of racial disparities; however, most supported interventions such as increasing clinician awareness (84%) and cultural competency training (88%).

CONCLUSIONS

Most primary-care clinicians support the collection of data on patients' race, but increased awareness about racial disparities at the local level is needed as part of a targeted effort to improve health care for minority patients.

Cardiovascular health disparities: a systematic review of health care interventions

Racial and ethnic disparities in cardiovascular health care are well documented. Promising approaches to disparity reduction are increasingly described in literature published since 1995, but reports are fragmented by risk, condition, population, and setting. The authors conducted a systematic review of clinically oriented studies in communities of color that addressed hypertension, hyperlipidemia, physical inactivity, tobacco, and two major cardiovascular conditions, coronary artery disease and heart failure. Virtually no literature specifically addressed disparity reduction. The greatest focus has been African American populations, with relatively little work in Hispanic, Asian, and Native American populations. The authors found 62 interventions, 27 addressing hypertension, 9 lipids, 18 tobacco use, 8 physical inactivity, and 7 heart failure. Only 1 study specifically addressed postmyocardial infarction care. Data supporting the value of registries, multidisciplinary teams, and community outreach were found across several conditions. Interventions addressing care transitions, using telephonic outreach, and promoting medication access and adherence merit further exploration.

Use of preventive care by elderly male veterans receiving care through the Veterans Health Administration, Medicare fee-for-service, and Medicare HMO plans

OBJECTIVES

We compared use of preventive care among veterans receiving care through the Veterans Health Administration (VHA), Medicare fee-for-service (FFS) plans, and Medicare health maintenance organizations (HMOs).

METHODS

Using both the Costs and Use, and Access to Care files of the Medicare Current Beneficiary Survey (2000-2003), we performed a cross-sectional analysis examining self-reported use of influenza vaccination, pneumococcal vaccination, serum cholesterol screening, and serum prostate-specific antigen measurement among male veterans 65 years or older. Veterans' care was categorized as received through VHA, Medicare FFS, Medicare HMOs, VHA and Medicare FFS, or VHA and Medicare HMOs.

RESULTS

Veterans receiving care through VHA reported 10% greater use of influenza vaccination (P<.05), 14% greater use of pneumococcal vaccination (P<.01), a nonsignificant 6% greater use of serum cholesterol screening (P=.1), and 15% greater use of prostate cancer screening (P<.01) than did veterans receiving care through Medicare HMOs. Veterans receiving care through Medicare FFS reported less use of all 4 preventive measures (P<.01) than did veterans receiving care through Medicare HMOs.

CONCLUSIONS

Receiving care through VHA was associated with greater use of preventive care.

Changes in Racial Disparities in Access to Coronary Artery Bypass Grafting Surgery Between the Late 1990s and Early 2000s

BACKGROUND

Racial disparities in medical care in the United States are pervasive and persistent. Minorities, African American patients in particular, have lower utilization rates for coronary artery bypass graft surgery (CABG) and, compared with white patients, they receive care from surgeons with worse records of performance.

OBJECTIVES

We sought to examine the persistence of disparities in CABG care (overall access to surgery and access to high-quality surgeons) in recent years and the potential causes for declining disparities.

MATERIALS AND METHODS

We undertook a retrospective analysis of data comparing access to CABG surgery and access to high-quality cardiac surgeons for white and black patients in the late 1990s and the early 2000s. Data used included the Medicare inpatient and physician part B claims and the New York State Cardiac Surgery Reports. A total of 24,087 Medicare fee-for-service patients undergoing CABG surgery between the years 1997-1999 and 23,048 patients undergoing CABG surgery between the years of 2001-2003 in New York State were studied. We measured the number of patients undergoing surgery by race and quality of surgeons measured by the surgeons' risk-adjusted mortality rates.

CONCLUSIONS

Disparities have declined between the 2 periods. The decline seems to be associated with freed surgical capacity among all surgeons, although other factors may also present barriers, especially in terms of overall access to surgery. Despite the decline in disparities, gaps in care received by white and black patients remain.

Effectiveness of Disease Management Programs on Improving Diabetes Care for Individuals in Health-Disparate Areas

In addition to race and ethnicity, specific geographic regions are associated with poorer outcomes of care. Individuals with diabetes experiencing health disparities typically have worse long-term outcomes, such as increased diabetes complications and mortality. Zip code mapping, or geocoding, was utilized in this study to identify regions of the United States with high diabetes prevalence rates and to identify areas with high densities of minority populations. Use of this methodology to examine the effect of disease management on a large, diverse diabetes population revealed greater improvement in clinical testing rates in health disparity zones compared with members living outside of these areas. In particular, significant improvement was achieved by members living in minority zip codes and by members aged 65 years or older. These findings demonstrate that members living in areas of health disparity obtain even greater benefit from diabetes disease management program participation, helping to reduce gaps in care.

Gender and racial disparities in the management of diabetes mellitus among Medicare patients

BACKGROUND

Racial/ethnic disparities in diabetes care have been demonstrated in several settings, but few studies have evaluated whether racial/ethnic differences vary by gender. The objective of this study is to understand gender and racial effects on diabetes care for Medicare managed care beneficiaries.

METHODS

Using data from: (1) Healthcare Effectiveness Data and Information Set (HEDIS); (2) Medicare Enrollment Files; and (3) U.S. Census, hierarchical generalized linear analyses were conducted to model the six HEDIS comprehensive diabetes care quality indicators, including processes of care and intermediate outcome measures, as a function of gender and race/ethnicity.

RESULTS

Women were more likely to have received HbA(1c) screening or eye examination, but less likely to have LDL control at <100 mg/dL, compared to men. Racial disparities favored whites in five measures, where African Americans were less likely to have received HbA(1c) screening, eye examination, cholesterol screening, or achieve adequate HbA(1c) control or LDL control at <100 mg/dL. Enrollees in managed care plans where African Americans constituted more than 20% of their insured population tended to have lower likelihood of meeting the HbA(1c) screening, HbA(1c) control, and eye examination measures.

CONCLUSIONS AND DISCUSSION

Gender and racial disparities in performance indicators were present among persons enrolled in Medicare managed care. White women were more likely to have met the performance measures related to process of care, but African Americans fared worse in both process of care and intermediate health outcome measures, compared to their white counterparts. Poor performance in cholesterol control observed in women of both races suggests the possibility of less intensive cholesterol treatment in women. The differences in the pattern of care demonstrate the need for interventions tailored to address gender and race/ethnicity.

Looking forward: cross-cutting issues in the collection and use of racial/ethnic data

Availability of reliable and valid race/ethnicity data is essential for monitoring and improving quality of care for minority groups. We explore the limitations and challenges posed by existing means of data collection and discuss issues that need to be considered as the data are analyzed and used.

Addressing racial and ethnic disparities in health care: using federal data to support local programs to eliminate disparities

To reduce racial and ethnic disparities in health care, managers, policy makers, and researchers need valid and reliable data on the race and ethnicity of individuals and populations. The federal government is one of the most important sources of such data. In this paper we review the strengths and weaknesses of federal data that pertain to racial and ethnic disparities in health care. We describe recent developments that are likely to influence how these data can be used in the future and discuss how local programs could make use of these data.

Mammography Self-Report and Mammography Claims

BACKGROUND

National self-report surveys show minimal racial disparity in mammography, whereas analyses of administrative data show large disparity.

METHODS

Using the 1998-2002 Medicare Current Beneficiary Surveys, which contain participants' self-report and claims data, we developed multivariable adjusted models examining factors associated with self-reported mammography and self-reported mammography verified by billing records.

RESULTS

No racial/ethnic disparities were found in self-reported mammography. Verified mammography, however, revealed significant disparities for race, education, income, insurance, and health status.

CONCLUSIONS

Race, education, income, insurance, and health status are associated with a lower likelihood of self-reported mammography verified by the existence of claims data. These data caution against exclusive reliance on self-report survey data to assess disparity in mammography.

Differences in prescription opioid analgesic availability: comparing minority and white pharmacies across Michigan

Little is known about physical barriers to adequate pain treatment for minorities. This investigation explored sociodemographic determinants of pain medication availability in Michigan pharmacies. A cross-sectional survey-based study with census data and data provided by Michigan community retail pharmacists was designed. Sufficient opioid analgesic supplies was defined as stocking at least one long-acting, short-acting, and combination opioid analgesic. Pharmacies located in minority (<or=70% minority residents) and white (>or=70% white residents) zip code areas were randomly selected by using a 2-stage sampling selection process (response rate, 80%). For the 190 pharmacies surveyed, most were located in white areas (51.6%) and had sufficient supplies (84.1%). After accounting for zip code median age and stratifying by income, pharmacies in white areas (odds ratio, 13.36 high income vs 54.42 low income) and noncorporate pharmacies (odds ratio, 24.92 high income vs 3.61 low income) were more likely to have sufficient opioid analgesic supplies (P < .005). Racial differences in the odds of having a sufficient supply were significantly higher in low income areas when compared with high income areas. Having a pharmacy located near a hospital did not change the availability for opioid analgesics. Persons living in predominantly minority areas experienced significant barriers to accessing pain medication, with greater disparities in low income areas regardless of ethnic composition. Differences were also found on the basis of pharmacy type, suggesting variability in pharmacist's decision making.

PERSPECTIVE

Michigan pharmacies in minority zip codes were 52 times less likely to carry sufficient opioid analgesics than pharmacies in white zip codes regardless of income. Lower income areas and corporate pharmacies were less likely to carry sufficient opioid analgesics. This study illustrates barriers to pain care and has public health implications.

Information technology as a tool to improve the quality of American Indian health care

The American Indian/Alaska Native population experiences a disproportionate burden of disease across a spectrum of conditions. While the recent National Healthcare Disparities Report highlighted differences in quality of care among racial and ethnic groups, there was only very limited information available for American Indians. The Indian Health Service (IHS) is currently enhancing its information systems to improve the measurement of health care quality as well as to support quality improvement initiatives. We summarize current knowledge regarding health care quality for American Indians, highlighting the variation in reported measures in the existing literature. We then discuss how the IHS is using information systems to produce standardized performance measures and present future directions for improving American Indian health care quality.

Trends in the quality of care and racial disparities in Medicare managed care

BACKGROUND

Since 1997, all managed-care plans administered by Medicare have reported on quality-of-care measures from the Health Plan Employer Data and Information Set (HEDIS). Studies of early data found that blacks received care that was of lower quality than that received by whites. In this study, we assessed changes over time in the overall quality of care and in the magnitude of racial disparities in nine measures of clinical performance.

METHODS

In order to compare the quality of care for elderly white and black beneficiaries enrolled in Medicare managed-care plans who were eligible for at least one of nine HEDIS measures, we analyzed 1.8 million individual-level observations from 183 health plans from 1997 to 2003. For each measure, we assessed whether the magnitude of the racial disparity had changed over time with the use of multivariable models that adjusted for the age, sex, health plan, Medicaid eligibility, and socioeconomic position of beneficiaries on the basis of their area of residence.

RESULTS

During the seven-year study period, clinical performance improved on all measures for both white enrollees and black enrollees (P<0.001). The gap between white beneficiaries and black beneficiaries narrowed for seven HEDIS measures (P<0.01). However, racial disparities did not decrease for glucose control among patients with diabetes (increasing from 4 percent to 7 percent, P<0.001) or for cholesterol control among patients with cardiovascular disorders (increasing from 14 percent to 17 percent; change not significant, P=0.72).

CONCLUSIONS

The measured quality of care for elderly Medicare beneficiaries in managed-care plans improved substantially from 1997 to 2003. Racial disparities declined for most, but not all, HEDIS measures we studied. Future research should examine factors that contributed to the narrowing of racial disparities on some measures and focus on interventions to eliminate persistent disparities in the quality of care.

Disparities and quality improvement: federal policy levers

Using a quality improvement framework to address racial and ethnic disparities in health care highlights multiple opportunities for federal and state governments to exert policy leverage, particularly through their roles as purchasers and regulators. Under such a framework, federal and state governments can expand their roles in collecting race/ethnicity data; define universal and meaningful race/ethnicity categories; more broadly disseminate standards for cultural competence; and demand the reduction of disparities through leveraging their status as collectively the largest U.S. health care payer.

Mortality of white Americans, African Americans, and Canadians: the causes and consequences for health of welfare state institutions and policies

The life expectancy of African Americans has been substantially lower than that of white Americans for as long as records are available. The life expectancy of all Americans has been lower than that of all Canadians since the beginning of the 20th century. Until the 1970s this disparity was the result of the low life expectancy of African Americans. Since then, the life expectancy of white Americans has not improved as much as that of all Canadians. This article discusses two issues: racial disparities in the United States, and the difference in life expectancy between all Canadians and white Americans. Each country's political culture and institutions have shaped these differences, especially national health insurance in Canada and its absence in the United States. The American welfare state has contributed to and explains these differences.

Changes in rates of beta-blocker use in community hospital patients with acute myocardial infarction

OBJECTIVE

To examine changes in the rate of beta-blocker (BB) use at admission, in hospital, and at discharge between 1994 and 1995 (MICH I) and 1997 (MICH II) in patients with acute myocardial infarction (AMI).

DESIGN

Comparison of two prospectively enrolled cohorts.

SETTING

Five mid-Michigan community hospitals.

PATIENTS

We studied 287 MICH I patients and 121 MICH II patients with AMI who had no contraindications to BB use from cohorts of consecutively admitted cases of AMI (814 in MICH I; 500 in MICH II).

RESULTS

Prescription of BBs to ideal patients with AMI increased in patients with previous history of myocardial infarction on arrival at the hospital (12.5% vs 36.0%; P= .01), in hospital (47.0% vs 76%; P < .01), and at discharge (34.0% vs 61.9%; P < .01). Neither race nor gender was a predictor of BB use. Younger age predicted BB prescription at discharge (odds ratio [OR], 2.07; 95% confidence interval [CI], 1.32 to 3.23). Later study cohort was the most important predictor of BB use in hospital (OR, 3.4; 95% CI, 2.09 to 5.25).

CONCLUSION

BB use improved dramatically over the study period, but additional work is needed to improve use of BB after discharge and among elderly patients with AMI.

Differences in diabetes prevalence, incidence, and mortality among the elderly of four racial/ethnic groups: whites, blacks, hispanics, and asians

OBJECTIVE

To examine diabetes prevalence, incidence, and mortality from 1993 to 2001 among fee-for-service Medicare beneficiaries > or = 67 years of age.

RESEARCH DESIGN AND METHODS

This study was a retrospective analysis of a 5% random sample of Medicare fee-for-service beneficiaries > or = 65 years of age in each year.

RESULTS

In 1993, the prevalence of diabetes among those > or = 67 years of age was 145 cases per 1,000 individuals. By 2001, it was 197/1,000, an increase of 36.0%. The 2001 prevalence among Hispanics (334/1,000) was significantly higher than among blacks (296/1,000), Asians (243/1,000), and whites (184/1,000, P < 0.0001). During the 7-year period the greatest increase in diabetes prevalence was among Asians (68.0%). Between 1994 and 2001, the annual rate of newly diagnosed elderly individuals with diabetes increased by 36.9%. Hispanics had the greatest increase at 55.0%. The mortality rate among individuals with diabetes decreased by approximately 5% between 1994 and 2001 from 92.1/1,000 to 87.2/1,000 (P < 0.001), due to a 6% decrease among whites. No decrease in mortality was seen among elderly individuals without diabetes, it was 55/1,000 in 1994 and 54/1,000 in 2001.

CONCLUSIONS

The dramatic increase in the incidence and prevalence of diabetes likely reflect a combination of true increases, as well as changes in the diagnostic criteria and increased interest in diagnosing and appropriately treating diabetes in the elderly. Improved treatment may have had an impact on mortality rates among individuals with diabetes, although they could have been influenced by the duration of diabetes before diagnosis, which has likely decreased. Changes in incidence, prevalence, and mortality in elderly individuals with diabetes need to continue to be monitored.

Associations of race, education, and patterns of preventive service use with stage of cancer at time of diagnosis

OBJECTIVE

To go beyond the documentation of disparities by race and SES by analyzing health behaviors regarding preventive and cancer screening services and determining if these behaviors are associated with stage of cancer when first diagnosed.

DATA

Stage of cancer for Medicare patients diagnosed in 1995 with breast, colorectal, uterine, ovarian, prostate, bladder, or stomach cancer; and use of influenza and pneumonia immunization, mammography, pap smear, colon cancer screening, and the prostate specific antigen test during the two years preceding diagnosis of cancer.

STUDY DESIGN

Hypothesis tested: health behaviors regarding use of preventive and cancer screening services are associated with stage of cancer when first diagnosed.

DATA COLLECTION/EXTRACTION METHODS

Information was extracted from the database formed by the linkage of Surveillance, Epidemiology, and End Results (SEER) cancer registries with Medicare files.

PRINCIPAL FINDINGS

Black and white patients (of higher and lower SES) who used more of the preventive and cancer screening services were at a lower risk of having late stage cancer for six cancers studied (breast, colorectal [male and female], prostate, uterine, and male bladder cancer) than their counterparts who used fewer of these services.

CONCLUSIONS

The use of preventive and cancer screening services is a health behavior associated with better health outcomes for the elderly diagnosed with cancer. The lack of preventive service use can serve as a marker for identifying persons at risk of late stage cancer when first diagnosed. Strategies that encourage the use of preventive services by low users of these services are likely to reinforce a range of healthy behaviors that help to ameliorate disparities in health outcomes.