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

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.

Examination of Racial Disparities in the Receipt of Minimally Invasive Surgery Among a National Cohort of Adult Patients Undergoing Colorectal Surgery

BACKGROUND

Racial disparities in outcomes are well described among surgical patients.

OBJECTIVE

The purpose of this work was to identify any racial disparities in the receipt of a minimally invasive approach for colorectal surgery.

DESIGN

Adults undergoing colorectal surgery were studied using the University HealthSystem Consortium. Univariate and multivariable analyses were used to identify predictors for the receipt of a minimally invasive approach.

SETTINGS

The study was conducted at academic hospitals and their affiliates.

PATIENTS

Adults ≥18 years of age who underwent surgery for colorectal cancer, diverticular disease, IBD, or benign colorectal tumor between 2008 and 2011 were included.

MAIN OUTCOME MEASURES

The receipt of a minimally invasive surgical approach was the main measured outcome.

RESULTS

A total of 82,474 adult patients met the study inclusion criteria. Of these, 69,664 (84%) were white, 10,874 (13%) were black, and 1936 (2%) were Asian. Blacks were younger, with higher rates of public insurance and higher comorbidity burden and baseline severity of illness compared with white and Asian patients. Black patients were less likely (adjusted OR = 0.83 (95% CI, 0.79-0.87)) and Asian patients more likely (adjusted OR = 1.34 (95% CI, 1.21-1.49)) than whites to receive minimally invasive surgery. This association did not change with stratification by insurance type (public or private). Black patients had higher rates of intensive care unit admission and nonhome discharge, as well as an increased length of stay compared with white and Asian patients. No differences in complications, readmission, or mortality rates were observed with minimally invasive surgery, but black patients were more likely to be readmitted or to die with open surgery.

LIMITATIONS

The study was limited by the retrospective nature of its data.

CONCLUSIONS

We identified racial differences in the receipt of a minimally invasive approach for colorectal surgery, regardless of insurance status, as well as improved outcomes for minority races who underwent a minimally invasive technique compared with open surgery. The improved outcomes associated with minimally invasive surgery should prompt efforts to increase rates of its use among black patients.

Discrepancies in Race and Ethnicity Documentation: a Potential Barrier in Identifying Racial and Ethnic Disparities

BACKGROUND

Data collection on race and ethnicity is critical in the assessment of racial disparities related to health. Studies comparing clinical and administrative data show discrepancies in race documentation and attribution.

METHODS

Self-reported data from two studies were compared to demographics in the electronic health record (EHR) extracted from the Biomedical Translational Research Information System (BTRIS) repository. McNemar and Bhapkar analyses were conducted to quantify the agreement of ethnicity and race between self-reported and EHR data. Pearson's chi-square tests were used to explore the relationship between acculturation, length of time in the USA, country of residence, and how individuals self-reported their race.

RESULTS

The sample (n = 280) was predominantly female (52.1 %), with a mean age of 47 (SD ± 13.74), mean years in the USA were 12.8 (SD ± 11.67) and the majority were born outside of the USA. (55.6 %). Those who self-identified as Hispanic (n = 208) scored a mean of 5.5 (SD ± 3.07) on the short acculturation scale (SAS) that ranges 4 to 20; lower scores indicate less acculturation. A significant difference was found between the way race is reported in the electronic medical record and self-reported data among those people who identified as Hispanic, with significant differences in the white (p < 0.0001) and other (p < 0.0001) categories.

CONCLUSIONS

The misclassification of race is most frequent in those individuals who self-identified as Hispanic. As the Hispanic population in the USA continues to grow, understanding the factors that affect the way that individuals from this heterogeneous population self-report race may provide important guidance in tailoring care to address health disparities.

Adverse inpatient outcomes during the transition to a new electronic health record system: observational study

OBJECTIVE

 To assess the short term association of inpatient implementation of electronic health records (EHRs) with patient outcomes of mortality, readmissions, and adverse safety events.

DESIGN

 Observational study with difference-in-differences analysis.

SETTING

 Medicare, 2011-12.

PARTICIPANTS

 Patients admitted to 17 study hospitals with a verifiable "go live" date for implementation of inpatient EHRs during 2011-12, and 399 control hospitals in the same hospital referral region.

MAIN OUTCOME MEASURES

 All cause readmission within 30 days of discharge, all cause mortality within 30 days of admission, and adverse safety events as defined by the patient safety for selected indicators (PSI)-90 composite measure among Medicare beneficiaries admitted to one of these hospitals 90 days before and 90 days after implementation of the EHRs (n=28 235 and 26 453 admissions), compared with the control group of all contemporaneous admissions to hospitals in the same hospital referral region (n=284 632 and 276 513 admissions). Analyses were adjusted for beneficiaries' sociodemographic and clinical characteristics.

RESULTS

 Before and after implementation, characteristics of admissions were similar in both study and control hospitals. Among study hospitals, unadjusted 30 day mortality (6.74% to 7.15%, P=0.06) and adverse safety event rates (10.5 to 11.4 events per 1000 admissions, P=0.34) did not significantly change after implementation of EHRs. There was an unadjusted decrease in 30 day readmission rates, from 19.9% to 19.0% post-implementation (P=0.02). In difference-in-differences analysis, however, there was no significant change in any outcome between pre-implementation and post-implementation periods (all P≥0.13).

CONCLUSIONS

 Despite concerns that implementation of EHRs might adversely impact patient care during the acute transition period, we found no overall negative association of such implementation on short term inpatient mortality, adverse safety events, or readmissions in the Medicare population across 17 US hospitals.

Disparities in Discontinuing Rosiglitazone Following the 2007 FDA Safety Alert

BACKGROUND

Responsiveness to the Food and Drug Administration (FDA) rosiglitazone safety alert, issued on May 21, 2007, has not been examined among vulnerable subpopulations of the elderly.

OBJECTIVE

To compare time to discontinuation of rosiglitazone after the safety alert between black and white elderly persons, and across sociodemographic and economic subgroups.

RESEARCH DESIGN

A cohort study.

SUBJECTS

Medicare fee-for-service enrollees in 2007 who were established users of rosiglitazone identified from a 20% national sample of pharmacy claims.

MEASURES

Outcome of interest was time to discontinuation of rosiglitazone after the May alert. We modeled the number of days following the warning to the end of the days' supply for the last rosiglitazone claim during the study period (May 21, 2007-December 31, 2007) using multivariable proportional hazards models.

RESULTS

More than 67% of enrollees discontinued rosiglitazone within six months of the advisory. In adjusted analysis, white enrollees (hazard ratio=0.90; 95% confidence interval, 0.86-0.94) discontinued rosiglitazone later than the comparison group of black enrollees. Enrollees with a history of low personal income also discontinued later than their comparison group (hazard ratio=0.84; 95% confidence interval, 0.81-0.87). There were no observed differences across quintiles of area-level socioeconomic status.

CONCLUSIONS

White race and a history of low personal income modestly predicted later discontinuation of rosiglitazone after the FDA's safety advisory in 2007. The impact of FDA advisories can vary among sociodemographic groups. Policymakers should continue to monitor whether risk management policies reach their intended populations.

Early Performance of Accountable Care Organizations in Medicare

BACKGROUND

In the Medicare Shared Savings Program (MSSP), accountable care organizations (ACOs) have financial incentives to lower spending and improve quality. We used quasi-experimental methods to assess the early performance of MSSP ACOs.

METHODS

Using Medicare claims from 2009 through 2013 and a difference-in-differences design, we compared changes in spending and in performance on quality measures from before the start of ACO contracts to after the start of the contracts between beneficiaries served by the 220 ACOs entering the MSSP in mid-2012 (2012 ACO cohort) or January 2013 (2013 ACO cohort) and those served by non-ACO providers (control group), with adjustment for geographic area and beneficiary characteristics. We analyzed the 2012 and 2013 ACO cohorts separately because entry time could reflect the capacity of an ACO to achieve savings. We compared ACO savings according to organizational structure, baseline spending, and concurrent ACO contracting with commercial insurers.

RESULTS

Adjusted Medicare spending and spending trends were similar in the ACO cohorts and the control group during the precontract period. In 2013, the differential change (i.e., the between-group difference in the change from the precontract period) in total adjusted annual spending was -$144 per beneficiary in the 2012 ACO cohort as compared with the control group (P=0.02), consistent with a 1.4% savings, but only -$3 per beneficiary in the 2013 ACO cohort as compared with the control group (P=0.96). Estimated savings were consistently greater in independent primary care groups than in hospital-integrated groups among 2012 and 2013 MSSP entrants (P=0.005 for interaction). MSSP contracts were associated with improved performance on some quality measures and unchanged performance on others.

CONCLUSIONS

The first full year of MSSP contracts was associated with early reductions in Medicare spending among 2012 entrants but not among 2013 entrants. Savings were greater in independent primary care groups than in hospital-integrated groups.

Disparities in Use of Human Epidermal Growth Hormone Receptor 2-Targeted Therapy for Early-Stage Breast Cancer

PURPOSE

Trastuzumab is a key component of adjuvant therapy for stage I to III human epidermal growth factor receptor 2 (HER2)-positive breast cancer. The rates and patterns of trastuzumab use have never been described in a population-based sample. The recent addition of HER2 information to the SEER-Medicare database offers an opportunity to examine patterns of trastuzumab use and to evaluate possible disparities in receipt of trastuzumab.

METHODS

We examined a national cohort of Medicare beneficiaries with incident stage I to III HER2-positive breast cancer diagnosed in 2010 and 2011 (n = 1,362). We used insurance claims data to track any use of trastuzumab in the 12 months after diagnosis as well as to identify chemotherapy drugs used in partnership with trastuzumab. We used modified Poisson regression analysis to evaluate the independent effect of race on likelihood of receiving trastuzumab by controlling for clinical need, comorbidity, and community-level socioeconomic status.

RESULTS

Overall, 50% of white women and 40% of black women received some trastuzumab therapy. Among women with stage III disease, 74% of whites and 56% of blacks received trastuzumab. After adjustment for tumor characteristics, poverty, and comorbidity, black women were 25% less likely to receive trastuzumab within 1 year of diagnosis than white women (risk ratio, 0.745; 95% CI, 0.60 to 0.93).

CONCLUSION

Approxemately one half of patients 65 years of age and older with stage I to III breast cancer do not receive trastuzumab-based therapy, which includes many with locally advanced disease. Significant racial disparities exist in the receipt of this highly effective therapy. Further research that identifies barriers to use and increases uptake of trastuzumab could potentially improve recurrence and survival outcomes in this population, particularly among minority women.

Assessing race and ethnicity data quality across cancer registries and EMRs in two hospitals

BACKGROUND

Measurement of patient race/ethnicity in electronic health records is mandated and important for tracking health disparities.

OBJECTIVE

Characterize the quality of race/ethnicity data collection efforts.

METHODS

For all cancer patients diagnosed (2007-2010) at two hospitals, we extracted demographic data from five sources: 1) a university hospital cancer registry, 2) a university electronic medical record (EMR), 3) a community hospital cancer registry, 4) a community EMR, and 5) a joint clinical research registry. The patients whose data we examined (N = 17 834) contributed 41 025 entries (range: 2-5 per patient across sources), and the source comparisons generated 1-10 unique pairs per patient. We used generalized estimating equations, chi-squares tests, and kappas estimates to assess data availability and agreement.

RESULTS

Compared to sex and insurance status, race/ethnicity information was significantly less likely to be available (χ(2 )> 8043, P < .001), with variation across sources (χ(2 )> 10 589, P < .001). The university EMR had a high prevalence of "Unknown" values. Aggregate kappa estimates across the sources was 0.45 (95% confidence interval, 0.45-0.45; N = 31 276 unique pairs), but improved in sensitivity analyses that excluded the university EMR source (κ = 0.89). Race/ethnicity data were in complete agreement for only 6988 patients (39.2%). Pairs with a "Black" data value in one of the sources had the highest agreement (95.3%), whereas pairs with an "Other" value exhibited the lowest agreement across sources (11.1%).

DISCUSSION

Our findings suggest that high-quality race/ethnicity data are attainable. Many of the "errors" in race/ethnicity data are caused by missing or "Unknown" data values.

CONCLUSIONS

To facilitate transparent reporting of healthcare delivery outcomes by race/ethnicity, healthcare systems need to monitor and enforce race/ethnicity data collection standards.

Do Lung Cancer Eligibility Criteria Align with Risk among Blacks and Hispanics?

BACKGROUND

Black patients have higher lung cancer risk despite lower pack years of smoking. We assessed lung cancer risk by race, ethnicity, and sex among a nationally representative population eligible for lung cancer screening based on Medicare criteria.

METHODS

We used data from the National Health and Nutrition Examination Survey, 2007-2012 to assess lung cancer risk by sex, race and ethnicity among persons satisfying Medicare age and pack-year smoking eligibility criteria for lung cancer screening. We assessed Medicare eligibility based on age (55-77 years) and pack-years (≥ 30). We assessed 6-year lung cancer risk using a risk prediction model from Prostate, Lung, Colorectal and Ovarian Cancer Screening trial that was modified in 2012 (PLCOm2012). We compared the proportions of eligible persons by sex, race and ethnicity using Medicare criteria with a risk cut-point that was adjusted to achieve comparable total number of persons eligible for screening.

RESULTS

Among the 29.7 million persons aged 55-77 years who ever smoked, we found that 7.3 million (24.5%) were eligible for lung cancer screening under Medicare criteria. Among those eligible, Blacks had statistically significant higher (4.4%) and Hispanics lower lung cancer risk (1.2%) than non-Hispanic Whites (3.2%). At a cut-point of 2.12% risk for lung screening eligibility, the percentage of Blacks and Hispanics showed statistically significant changes. Blacks eligible rose by 48% and Hispanics eligible declined by 63%. Black men and Hispanic women were affected the most. There was little change in eligibility among Whites.

CONCLUSION

Medicare eligibility criteria for lung cancer screening do not align with estimated risk for lung cancer among Blacks and Hispanics. Data are urgently needed to determine whether use of risk-based eligibility screening improves lung cancer outcomes among minority patients.

Concordance between Self-Reports and Medicare Claims among Participants in a National Study of Chronic Disease Self-Management Program

OBJECTIVES

To evaluate the concordance between self-reported data and variables obtained from Medicare administrative data in terms of chronic conditions and health care utilization.

DESIGN

Retrospective observational study.

PARTICIPANTS

We analyzed data from a sample of Medicare beneficiaries who were part of the National Study of Chronic Disease Self-Management Program (CDSMP) and were eligible for the Centers for Medicare and Medicaid Services (CMS) pilot evaluation of CDSMP (n = 119).

METHODS

Self-reported and Medicare claims-based chronic conditions and health care utilization were examined. Percent of consistent numbers, kappa statistic (κ), and Pearson's correlation coefficient were used to evaluate concordance.

RESULTS

The two data sources had substantial agreement for diabetes and chronic obstructive pulmonary disease (COPD) (κ = 0.75 and κ = 0.60, respectively), moderate agreement for cancer and heart disease (κ = 0.50 and κ = 0.47, respectively), and fair agreement for depression (κ = 0.26). With respect to health care utilization, the two data sources had almost perfect or substantial concordance for number of hospitalizations (κ = 0.69-0.79), moderate concordance for ED care utilization (κ = 0.45-0.61), and generally low agreement for number of physician visits (κ ≤ 0.31).

CONCLUSION

Either self-reports or claim-based administrative data for diabetes, COPD, and hospitalizations can be used to analyze Medicare beneficiaries in the US. Yet, caution must be taken when only one data source is available for other types of chronic conditions and health care utilization.

Psoriasis in the US Medicare Population: Prevalence, Treatment, and Factors Associated with Biologic Use

Psoriasis is a common chronic inflammatory disorder, primarily of the skin. Despite an aging population, knowledge of the epidemiology of psoriasis and its treatments among the elderly is limited. We examined the prevalence of psoriasis and its treatments, with a focus on biologics and identification of factors associated with biologic use, using a nationally representative sample of Medicare beneficiaries in 2011. On the basis of several psoriasis identification algorithms, the claims-based prevalence for psoriasis in the United States ranged from 0.51 to 1.23%. Treatments used for moderate-to-severe psoriasis (phototherapy, oral systemic, or biologic therapies) were received by 27.3% of the total psoriasis sample, of whom 37.2% used biologics. Patients without a Medicare Part D low-income subsidy (LIS) had 70% lower odds of having received biologics than those with LIS (odds ratio 0.30; 95% confidence interval, 0.19-0.46). Similarly, the odds of having received biologics were 69% lower among black patients compared with white patients (0.31; 0.16-0.60). This analysis identified potential financial and racial barriers to receipt of biologic therapies and underscores the need for additional studies to further define the epidemiology and treatment of psoriasis among the elderly.

Health literacy and 30-day hospital readmission after acute myocardial infarction

OBJECTIVE

To assess the validity of a predictive model of health literacy, and to examine the relationship between derived health literacy estimates and 30-day hospital readmissions for acute myocardial infarction (AMI).

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

A National Institute of Aging (NIA) study cohort of 696 adult, English-speaking primary care patients, aged 55-74 years, was used to assess the validity of derived health literacy estimates. Claims from 7733 Medicare beneficiaries hospitalised for AMI in 2008 in North Carolina and Illinois were used to investigate the association between health literacy estimates and 30-day hospital readmissions.

MEASURES

The NIA cohort was administered 3 common health literacy assessments (Newest Vital Sign, Test of Functional Health Literacy in Adults, and Rapid Estimate of Adult Literacy in Medicine). Health literacy estimates at the census block group level were derived via a predictive model. 30-day readmissions were measured from Medicare claims data using a validated algorithm.

RESULTS

Fair agreement was found between derived estimates and in-person literacy assessments (Pearson Correlation coefficients: 0.38-0.51; κ scores: 0.38-0.40). Medicare enrollees with above basic literacy according to derived health literacy estimates had an 18% lower risk of a 30-day readmission (RR=0.82, 95% CI 0.73 to 0.92) and 21% lower incidence rate of 30-day readmission (IRR=0.79, 95% CI 0.68 to 0.87) than patients with basic or below basic literacy. After adjusting for demographic and clinical characteristics, the risk of 30-day readmission was 12% lower (p=0.03), and the incidence rate 16% lower (p<0.01) for patients with above basic literacy.

CONCLUSIONS

Health literacy, as measured by a predictive model, was found to be a significant, independent predictor of 30-day readmissions. As a modifiable risk factor with evidence-based solutions, health literacy should be considered in readmission reduction efforts.

Medicare's Hospital Readmissions Reduction Program in Surgery May Disproportionately Affect Minority-serving Hospitals

OBJECTIVE

To project readmission penalties for hospitals performing cardiac surgery and examine how these penalties will affect minority-serving hospitals.

BACKGROUND

The Hospital Readmissions Reduction Program will potentially expand penalties for higher-than-predicted readmission rates to cardiac procedures in the near future. The impact of these penalties on minority-serving hospitals is unknown.

METHODS

We examined national Medicare beneficiaries undergoing coronary artery bypass grafting in 2008 to 2010 (N = 255,250 patients, 1186 hospitals). Using hierarchical logistic regression, we calculated hospital observed-to-expected readmission ratios. Hospital penalties were projected according to the Hospital Readmissions Reduction Program formula using only coronary artery bypass grafting readmissions with a 3% maximum penalty of total Medicare revenue. Hospitals were classified into quintiles according to proportion of black patients treated. Minority-serving hospitals were defined as hospitals in the top quintile whereas non-minority-serving hospitals were those in the bottom quintile. Projected readmission penalties were compared across quintiles.

RESULTS

Forty-seven percent of hospitals (559 of 1186) were projected to be assessed a penalty. Twenty-eight percent of hospitals (330 of 1186) would be penalized less than 1% of total Medicare revenue whereas 5% of hospitals (55 of 1186) would receive the maximum 3% penalty. Minority-serving hospitals were almost twice as likely to be penalized than non-minority-serving hospitals (61% vs 32%) and were projected almost triple the reductions in reimbursement ($112 million vs $41 million).

CONCLUSIONS

Minority-serving hospitals would disproportionately bear the burden of readmission penalties if expanded to include cardiac surgery. Given these hospitals' narrow profit margins, readmission penalties may have a profound impact on these hospitals' ability to care for disadvantaged patients.

Performance differences in year 1 of pioneer accountable care organizations

BACKGROUND

In 2012, a total of 32 organizations entered the Pioneer accountable care organization (ACO) program, in which providers can share savings with Medicare if spending falls below a financial benchmark. Performance differences associated with characteristics of Pioneer ACOs have not been well described.

METHODS

In a difference-in-differences analysis of Medicare fee-for-service claims, we compared Medicare spending for beneficiaries attributed to Pioneer ACOs (ACO group) with other beneficiaries (control group) before (2009 through 2011) and after (2012) the start of Pioneer ACO contracts, with adjustment for geographic area and beneficiaries' sociodemographic and clinical characteristics. We estimated differential changes in spending for several subgroups of ACOs: those with and those without clear financial integration between hospitals and physician groups, those with higher and those with lower baseline spending, and the 13 ACOs that withdrew from the Pioneer program after 2012 and the 19 that did not.

RESULTS

Adjusted Medicare spending and spending trends were similar in the ACO group and the control group during the precontract period. In 2012, the total adjusted per-beneficiary spending differentially changed in the ACO group as compared with the control group (-$29.2 per quarter, P=0.007), consistent with a 1.2% savings. Savings were significantly greater for ACOs with baseline spending above the local average, as compared with those with baseline spending below the local average (P=0.05 for interaction), and for those serving high-spending areas, as compared with those serving low-spending areas (P=0.04). Savings were similar in ACOs with financial integration between hospitals and physician groups and those without, as well as in ACOs that withdrew from the program and those that did not.

CONCLUSIONS

Year 1 of the Pioneer ACO program was associated with modest reductions in Medicare spending. Savings were greater for ACOs with higher baseline spending than for those with lower baseline spending and were unrelated to withdrawal from the program. (Funded by the National Institute on Aging and others.).

Race/Ethnicity and overuse of care: a systematic review

POLICY POINTS: Racial/ethnic differences in the overuse of care (specifically, unneeded care that does not improve patients' outcomes) have received little scholarly attention. Our systematic review of the literature (59 studies) found that the overuse of care is not invariably associated with race/ethnicity, but when it was, a substantial proportion of studies found greater overuse of care among white patients. The absence of established subject terms in PubMed for the overuse of care or inappropriate care impedes the ability of researchers or policymakers to synthesize prior scientific or policy efforts.

CONTEXT

The literature on disparities in health care has examined the contrast between white patients receiving needed care, compared with racial/ethnic minority patients not receiving needed care. Racial/ethnic differences in the overuse of care, that is, unneeded care that does not improve patients' outcomes, have received less attention. We systematically reviewed the literature regarding race/ethnicity and the overuse of care.

METHODS

We searched the Medline database for US studies that included at least 2 racial/ethnic groups and that examined the association between race/ethnicity and the overuse of procedures, diagnostic (care) or therapeutic care. In a recent review, we identified studies of overuse by race/ethnicity, and we also examined reference lists of retrieved articles. We then abstracted and evaluated this information, including the population studied, data source, sample size and assembly, type of care, guideline or appropriateness standard, controls for clinical confounding and financing of care, and findings.

FINDINGS

We identified 59 unique studies, of which 11 had a low risk of methodological bias. Studies with multiple outcomes were counted more than once; collectively they assessed 74 different outcomes. Thirty-two studies, 6 with low risks of bias (LRoB), provided evidence that whites received more inappropriate or nonrecommended care than racial/ethnic minorities did. Nine studies (2 LRoB) found evidence of more overuse of care by minorities than by whites. Thirty-three studies (6 LRoB) found no relationship between race/ethnicity and overuse.

CONCLUSIONS

Although the overuse of care is not invariably associated with race/ethnicity, when it was, a substantial proportion of studies found greater overuse of care among white patients. Clinicians and researchers should try to understand how and why race/ethnicity might be associated with overuse and to intervene to reduce it.

Unveiling SEER-CAHPS®: a new data resource for quality of care research

BACKGROUND

Since 1990, the National Cancer Institute (NCI) and Centers for Medicare and Medicaid Services (CMS) have collaborated to create linked data resources to improve our understanding of patterns of care, health care costs, and trends in utilization. However, existing data linkages have not included measures of patient experiences with care.

OBJECTIVE

To describe a new resource for quality of care research based on a linkage between the Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS®) patient surveys and the NCI's Surveillance, Epidemiology and End Results (SEER) data.

DESIGN

This is an observational study of CAHPS respondents and includes both fee-for-service and Medicare Advantage beneficiaries with and without cancer. The data linkage includes: CAHPS survey data collected between 1998 and 2010 to assess patient reports on multiple aspects of their care, such as access to needed and timely care, doctor communication, as well as patients' global ratings of their personal doctor, specialists, overall health care, and their health plan; SEER registry data (1973-2007) on cancer site, stage, treatment, death information, and patient demographics; and longitudinal Medicare claims data (2002-2011) for fee-for-service beneficiaries on utilization and costs of care.

PARTICIPANTS

In total, 150,750 respondents were in the cancer cohort and 571,318 were in the non-cancer cohort.

MAIN MEASURES

The data linkage includes SEER data on cancer site, stage, treatment, death information, and patient demographics, in addition to longitudinal data from Medicare claims and information on patient experiences from CAHPS surveys.

KEY RESULTS

Sizable proportions of cases from common cancers (e.g., breast, colorectal, prostate) and short-term survival cancers (e.g., pancreas) by time since diagnosis enable comparisons across the cancer care trajectory by MA vs. FFS coverage.

CONCLUSIONS

SEER-CAHPS is a valuable resource for information about Medicare beneficiaries' experiences of care across different diagnoses and treatment modalities, and enables comparisons by type of insurance.

Utilization of acute care among patients with ESRD discharged home from skilled nursing facilities

BACKGROUND AND OBJECTIVES

Older adults with ESRD often receive care in skilled nursing facilities (SNFs) after an acute hospitalization; however, little is known about acute care use after SNF discharge to home.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This study used Medicare claims for North and South Carolina to identify patients with ESRD who were discharged home from a SNF between January 1, 2010 and August 31, 2011. Nursing Home Compare data were used to ascertain SNF characteristics. The primary outcome was time from SNF discharge to first acute care use (hospitalization or emergency department visit) within 30 days. Cox proportional hazards models were used to identify patient and facility characteristics associated with the outcome.

RESULTS

Among 1223 patients with ESRD discharged home from a SNF after an acute hospitalization, 531 (43%) had at least one rehospitalization or emergency department visit within 30 days. The median time to first acute care use was 37 days. Characteristics associated with a shorter time to acute care use were black race (hazard ratio [HR], 1.25; 95% confidence interval [95% CI], 1.04 to 1.51), dual Medicare-Medicaid coverage (HR, 1.24; 95% CI, 1.03 to 1.50), higher Charlson comorbidity score (HR, 1.07; 95% CI, 1.01 to 1.12), number of hospitalizations during the 90 days before SNF admission (HR, 1.12; 95% CI, 1.03 to 1.22), and index hospital discharge diagnoses of cellulitis, abscess, and/or skin ulcer (HR, 2.59; 95% CI, 1.36 to 4.45). Home health use after SNF discharge was associated with a lower rate of acute care use (HR, 0.72; 95% CI, 0.59 to 0.87). There were no statistically significant associations between SNF characteristics and time to first acute care use.

CONCLUSIONS

Almost one in every two older adults with ESRD discharged home after a post-acute SNF stay used acute care services within 30 days of discharge. Strategies to reduce acute care utilization in these patients are needed.

Racial and ethnic disparities among enrollees in Medicare Advantage plans

BACKGROUND

Differences in the control of blood pressure, cholesterol, and glucose among the various racial and ethnic groups of Medicare enrollees may contribute to persistent disparities in health outcomes.

METHODS

Among elderly enrollees in Medicare Advantage health plans in 2011 who had hypertension (94,171 persons), cardiovascular disease (112,039), or diabetes (105,848), we compared the respective age-and-sex-adjusted proportions with blood pressure lower than 140/90 mm Hg, low-density lipoprotein cholesterol levels below 100 mg per deciliter (2.6 mmol per liter), and a glycated hemoglobin value of 9.0% or lower, according to race or ethnic group. Comparisons were made nationally and within regions and health plans, and changes since 2006 were assessed.

RESULTS

Black enrollees in 2006 and 2011 were substantially less likely than white enrollees to have adequate control of blood pressure (adjusted absolute differences in proportions of enrollees in the 2 years, 7.9 percentage points and 10.3 percentage points, respectively), cholesterol (11.4 percentage points and 10.2 percentage points, respectively), and glycated hemoglobin (10.1 percentage points and 9.4 percentage points, respectively) (P<0.001 for all comparisons). Differing distributions of enrollees among health plans accounted for 39 to 59% of observed disparities in 2011. These differences persisted in 2011 in the Northeast, Midwest, and South (6.9 to 14.1 percentage points, P<0.001 for all comparisons) but were eliminated in the West for all three measures (<1.5 percentage points, P≥0.15). Hispanic enrollees were less likely than whites in 2011 to have adequate control of blood pressure (adjusted difference, 1.6 percentage points), cholesterol (adjusted difference, 1.0 percentage points), and glycated hemoglobin (adjusted difference, 3.4 percentage points) (P≤0.02 for all comparisons). Asians and Pacific Islanders were more likely than whites to have adequate control of blood pressure (difference, 4.4 percentage points; P<0.001) and cholesterol (5.5 percentage points, P<0.001) and had similar control of glycated hemoglobin (0.3 percentage points, P=0.63).

CONCLUSIONS

Disparities in control of blood pressure, cholesterol, and glucose have not improved nationally for blacks in Medicare Advantage plans, but these disparities were eliminated in the West in 2011. (Funded by the National Institute on Aging.).

Changes in patients' experiences in Medicare Accountable Care Organizations

BACKGROUND

Incentives for accountable care organizations (ACOs) to limit health care use and improve quality may enhance or hurt patients' experiences with care.

METHODS

Using Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data covering 3 years before and 1 year after the start of Medicare ACO contracts in 2012 as well as linked Medicare claims, we compared patients' experiences in a group of 32,334 fee-for-service beneficiaries attributed to ACOs (ACO group) with those in a group of 251,593 beneficiaries attributed to other providers (control group), before and after the start of ACO contracts. We used linear regression and a difference-in-differences analysis to estimate changes in patients' experiences in the ACO group that differed from concurrent changes in the control group, with adjustment for the sociodemographic and clinical characteristics of the patients.

RESULTS

After ACO contracts began, patients' reports of timely access to care and their primary physicians' being informed about specialty care differentially improved in the ACO group, as compared with the control group (P=0.01 and P=0.006, respectively), whereas patients' ratings of physicians, interactions with physicians, and overall care did not differentially change. Among patients with multiple chronic conditions and high predicted Medicare spending, overall ratings of care differentially improved in the ACO group as compared with the control group (P=0.02). Differential improvements in timely access to care and overall ratings were equivalent to moving from average performance among ACOs to the 86th to 98th percentile (timely access to care) and to the 82nd to 96th percentile (overall ratings) and were robust to adjustment for group differences in trends during the preintervention period.

CONCLUSIONS

In the first year, ACO contracts were associated with meaningful improvements in some measures of patients' experience and with unchanged performance in others. (Funded by the National Institute on Aging and others.).

Racial disparities in adoption of axillary sentinel lymph node biopsy and lymphedema risk in women with breast cancer

IMPORTANCE

Racial disparities exist in many aspects of breast cancer care. Sentinel lymph node biopsy (SLNB) was developed to replace axillary lymph node dissection (ALND) for staging early breast cancer to minimize complications. Racial disparities in the use of SLNB remain incompletely characterized, and their effect on lymphedema risk is not known.

OBJECTIVE

To determine racial differences in SLNB use among patients with pathologically node-negative breast cancer during the period when SLNB became the preferred method for axillary staging as well as whether such differences affect lymphedema risk.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective study was conducted using the Surveillance, Epidemiology, and End Results-Medicare-linked database from 2002 through 2007 to identify cases of incident, nonmetastatic, pathologically node-negative breast cancer in women aged 66 years or older.

MAIN OUTCOMES AND MEASURES

Sentinel lymph node biopsy use and 5-year cumulative incidence of lymphedema by race.

RESULTS

Of 31 274 women identified, 1767 (5.6%) were black, 27 856 (89.1%) were white, and 1651 (5.3%) were of other or unknown race. Sentinel lymph node biopsy was performed in 73.7% of white patients and 62.4% of black patients (P < .001). The use of SLNB increased by year for both black and white patients (P < .001); however, a fixed disparity of approximately 12 percentage points in SLNB use persisted through 2007. In adjusted analysis, black patients were significantly less likely than white patients to undergo SLNB (odds ratio, 0.67; 95% CI, 0.60-0.75; P < .001). Overall, the 5-year cumulative lymphedema risk was 8.2% in whites and 12.3% in blacks (hazard ratio [HR], 1.43; 95% CI, 1.23-1.67; P < .001). When stratified by type of axillary surgery, 5-year lymphedema risk was 6.8% in whites undergoing SLNB (HR, 1 [reference]), 8.8% in blacks undergoing SLNB (HR, 1.28; 95% CI, 1.02-1.60; P = .03), 12.2% in whites undergoing ALND (1.79; 1.63-1.96; P < .001), and 18.0% in blacks undergoing ALND (2.76; 2.25-3.39; P < .001).

CONCLUSIONS AND RELEVANCE

Although SLNB use increased in both black and white patients with pathologically node-negative breast cancer from 2002 through 2007, the rates of SLNB remained lower in black than white patients during this entire period by approximately 12 percentage points. This racial disparity in SLNB use contributed to racial disparities in lymphedema risk. Improvements in the dissemination of new techniques are needed to avoid disparities in breast cancer care and patient outcomes, particularly in disadvantaged groups.

Quality of care and racial disparities in medicare among potential ACOs

BACKGROUND

The Medicare Accountable Care Organization (ACO) programs encourage integration of providers into large groups and reward provider groups for improving quality, but not explicitly for reducing health care disparities. Larger group size and better overall quality may or may not be associated with smaller disparities.

OBJECTIVE

To examine differences in patient characteristics between provider groups sufficiently large to participate in ACO programs and smaller groups; the association between group size and racial disparities in quality; and the association between quality and disparities among larger groups.

DESIGN AND PARTICIPANTS

Using 2009 Medicare claims for 3.1 million beneficiaries with cardiovascular disease or diabetes and linked data on provider groups, we compared racial differences in quality by provider group size, adjusting for patient characteristics. Among larger groups, we used multilevel models to estimate correlations between group performance on quality measures for white beneficiaries and black-white disparities within groups.

MAIN MEASURES

Four process measures of quality, hospitalization for ambulatory care-sensitive conditions (ACSCs) related to cardiovascular disease or diabetes, and hospitalization for any ACSC.

KEY RESULTS

Beneficiaries served by larger groups were more likely to be white and live in areas with less poverty and more education. Larger group size was associated with smaller disparities in low-density lipoprotein (LDL) cholesterol testing and retinal exams, but not in other process measures or hospitalization for ACSCs. Among larger groups, better quality for white beneficiaries in one measure (hospitalization for ACSCs related to cardiovascular disease or diabetes) was correlated with smaller racial disparities (r = 0.28; P = 0.02), but quality was not correlated with disparities in other measures.

CONCLUSIONS

Larger provider group size and better performance on quality measures were not consistently associated with smaller racial disparities in care for Medicare beneficiaries with cardiovascular disease or diabetes. ACO incentives rewarding better quality for minority groups and payment arrangements supporting ACO development in disadvantaged communities may be required for ACOs to promote greater equity in care.

Access to oral osteoporosis drugs among female Medicare Part D beneficiaries

BACKGROUND

For women living with osteoporosis, high out-of-pocket (OOP) drug costs may prevent drug therapy initiation. We investigate the association between oral osteoporosis OOP medication costs and female Medicare beneficiaries' initiation of osteoporosis drug therapy.

METHODS

We used 2007 and 2008 administrative claims and enrollment data for a 5% random sample of Medicare beneficiaries. Our study sample included age-qualified, female beneficiaries who had no prior history of osteoporosis but were diagnosed with osteoporosis in 2007 or 2008. Additionally, we only included beneficiaries continuously enrolled in stand-alone prescription drug plans. We excluded beneficiaries who had a chronic condition that was contraindicated with osteoporosis drug utilization. Our final sample included 25,069 beneficiaries. Logistic regression analysis was used to examine the association between the OOP costs and initiation of oral osteoporosis drug therapy during the year of diagnosis.

FINDINGS

Twenty-six percent of female Medicare beneficiaries newly diagnosed with osteoporosis initiated oral osteoporosis drug therapy. Beneficiaries' OOP costs were not associated with the initiation of drug therapy for osteoporosis. However, there were significant racial disparities in beneficiaries' initiation of drug therapy. African Americans were 3 percentage points less likely to initiate drug therapy than Whites. In contrast, Asian/Pacific Islander and Hispanic beneficiaries were 8 and 18 percentage points, respectively, more likely to initiate drug therapy than Whites. Additionally, institutionalized beneficiaries were 11 percentage points less likely to initiate drug therapy than other beneficiaries.

CONCLUSIONS

Access barriers for drug therapy initiation may be driven by factors other than patients' OOP costs. These results suggest that improved osteoporosis treatment requires a more comprehensive approach that goes beyond payment policies.

Identification of abnormal screening mammogram interpretation using Medicare claims data

OBJECTIVE

To develop and validate Medicare claims-based approaches for identifying abnormal screening mammography interpretation.

DATA SOURCES

Mammography data and linked Medicare claims for 387,709 mammograms performed from 1999 to 2005 within the Breast Cancer Surveillance Consortium (BCSC).

STUDY DESIGN

Split-sample validation of algorithms based on claims for breast imaging or biopsy following screening mammography.

DATA EXTRACTION METHODS

Medicare claims and BCSC mammography data were pooled at a central Statistical Coordinating Center.

PRINCIPAL FINDINGS

Presence of claims for subsequent imaging or biopsy had sensitivity of 74.9 percent (95 percent confidence interval [CI], 74.1-75.6) and specificity of 99.4 percent (95 percent CI, 99.4-99.5). A classification and regression tree improved sensitivity to 82.5 percent (95 percent CI, 81.9-83.2) but decreased specificity (96.6 percent, 95 percent CI, 96.6-96.8).

CONCLUSIONS

Medicare claims may be a feasible data source for research or quality improvement efforts addressing high rates of abnormal screening mammography.

Racial disparities in the treatment of advanced epithelial ovarian cancer

OBJECTIVE

To examine whether treatment with guideline-recommended care (surgery and chemotherapy) is associated with mortality differences between black and white women with advanced epithelial ovarian cancer.

METHODS

We conducted an observational cohort study using the Surveillance, Epidemiology, and End Results (SEER) linked to Medicare claims for 1995-2007. We evaluated long-term survival for 4,695 black and white women with stage III or stage IV epithelial ovarian cancer with Kaplan-Meier analysis and Cox regression, and then in patients matched by propensity score to create two similar cohorts for comparison. We investigated the association between race, stage, and survival among women who were treated with guideline-recommended care and those who received incomplete treatment.

RESULTS

Black women with advanced epithelial ovarian cancer were more likely to die than white women (unadjusted hazard ratio [HR] 1.27; 95% confidence interval [CI] 1.10-1.46). Black women were less likely than white women to receive guideline-recommended care (54% compared with 68%; P<.001), and women who did not receive recommended treatment had lower survival rates than women who received recommended care. Cox proportional hazards models demonstrated no differences in black women compared with white women regarding mortality among women who were treated with guideline-recommended care (adjusted HR 1.04; 95% CI 0.85-1.26), or among women who received incomplete treatment (adjusted HR 1.09; 95% CI 0.89-1.34). The survival analysis of patients matched by propensity score confirmed these analyses.

CONCLUSIONS

Differences in rates of treatment with guideline-recommended care are associated with black-white mortality disparities among women with advanced epithelial ovarian cancer.

LEVEL OF EVIDENCE

III.

Racial and ethnic differences in use of mammography between Medicare Advantage and traditional Medicare

BACKGROUND

Breast cancer is a leading cause of mortality for women in all racial/ethnic groups. We compared use of mammography by race/ethnicity in Medicare health maintenance organizations (HMOs), preferred provider organizations (PPOs), and traditional Medicare.

METHODS

We matched 495 836 women in HMOs and 81 480 women in PPOs who were aged 65 to 69 years during 2009 to women enrolled in traditional Medicare by race/ethnicity, Medicaid eligibility status, and geographic area. We identified mammography use from the Healthcare Effectiveness Data and Information Set for Medicare HMOs and PPOs and from claims data for traditional Medicare with the same specifications. We then compared racial/ethnic differences in rates of mammography in HMOs and PPOs to matched populations in traditional Medicare and estimated differences with z tests. All statistical tests were two-sided.

RESULTS

Relative to matched white women, mammography rates were statistically significantly higher for black, Hispanic, and Asian/Pacific Islander women in HMOs (6.1, 5.4, and 0.9 percentage points, respectively; all P ≤ .003) and statistically significantly lower for all three groups in traditional Medicare (3.3, 7.4, and 7.7 percentage points, respectively; all P < .001). Similar improvements in mammography rates also were observed in PPOs among all minority groups relative to traditional Medicare.

CONCLUSIONS

Higher rates of mammography in HMOs and PPOs were associated with a reversal of racial and ethnic differences observed in traditional Medicare. These differences may be related to lower patient cost-sharing and better systems to promote preventive services in managed care plans, as well as unmeasured characteristics or beliefs of minority women who enroll in these health plans relative to those in traditional Medicare.

Validity of infant race/ethnicity from birth certificates in the context of U.S. demographic change

OBJECTIVE

To compare infant race/ethnicity based on birth certificates with parent report of infant race/ethnicity in a survey.

DATA SOURCES

The 2007 Oklahoma birth certificates and SEED for Oklahoma Kids baseline survey.

STUDY DESIGN

Using sensitivity scores and positive predictive values, we examined consistency of infant race/ethnicity across two data sources (N = 2,663).

DATA COLLECTION/EXTRACTION METHODS

We compared conventional measures of infant race/ethnicity from birth certificate and survey data. We also tested alternative measures that allow biracial classification, determined from parental information on the infant's birth certificate or parental survey report.

PRINCIPAL FINDINGS

Sensitivity of conventional measures is highest for whites and African Americans and lowest for Hispanics; positive predictive value is highest for Hispanics and African Americans and lowest for American Indians. Alternative measures improve values among whites but yield mostly low values among minority and biracial groups.

CONCLUSIONS

Health disparities research should consider the source and validity of infant race/ethnicity data when creating sampling frames or designing studies that target infants by race/ethnicity. The common practice of assigning the maternal race/ethnicity as infant race/ethnicity should continue to be challenged.

Accuracy of routinely recorded ethnic group information compared with self-reported ethnicity: evidence from the English Cancer Patient Experience survey

OBJECTIVE

To describe the accuracy of ethnicity coding in contemporary National Health Service (NHS) hospital records compared with the 'gold standard' of self-reported ethnicity.

DESIGN

Secondary analysis of data from a cross-sectional survey (2011).

SETTING

All NHS hospitals in England providing cancer treatment.

PARTICIPANTS

58 721 patients with cancer for whom ethnicity information (Office for National Statistics 2001 16-group classification) was available from self-reports (considered to represent the 'gold standard') and their hospital record.

METHODS

We calculated the sensitivity and positive predictive value (PPV) of hospital record ethnicity. Further, we used a logistic regression model to explore independent predictors of discordance between recorded and self-reported ethnicity.

RESULTS

Overall, 4.9% (4.7-5.1%) of people had their self-reported ethnic group incorrectly recorded in their hospital records. Recorded White British ethnicity had high sensitivity (97.8% (97.7-98.0%)) and PPV (98.1% (98.0-98.2%)) for self-reported White British ethnicity. Recorded ethnicity information for the 15 other ethnic groups was substantially less accurate with 41.2% (39.7-42.7%) incorrect. Recorded 'Mixed' ethnicity had low sensitivity (12-31%) and PPVs (12-42%). Recorded 'Indian', 'Chinese', 'Black-Caribbean' and 'Black African' ethnic groups had intermediate levels of sensitivity (65-80%) and PPV (80-89%, respectively). In multivariable analysis, belonging to an ethnic minority group was the only independent predictor of discordant ethnicity information. There was strong evidence that the degree of discordance of ethnicity information varied substantially between different hospitals (p<0.0001).

DISCUSSION

Current levels of accuracy of ethnicity information in NHS hospital records support valid profiling of White/non-White ethnic differences. However, profiling of ethnic differences in process or outcome measures for specific minority groups may contain a substantial and variable degree of misclassification error. These considerations should be taken into account when interpreting ethnic variation audits based on routine data and inform initiatives aimed at improving the accuracy of ethnicity information in hospital records.

Recent trends in hip fracture rates by race/ethnicity among older US adults

Hip fracture incidence has declined among whites in the United States since 1995, but data on recent trends in racial and ethnic minorities are limited. The goal of this analysis was to investigate hip fracture incidence trends in racial/ethnic subgroups of older Medicare beneficiaries. We conducted a cohort study to determine annual hip fracture incidence rates from 2000 through 2009 using the Medicare national random 5% sample. Beneficiaries were eligible if they were ≥65 years of age and had 90 days of consecutive full fee-for-service Medicare coverage with no hip fracture claims. Race/ethnicity was self-reported. The incidence of hip fracture was identified using hospital diagnosis codes or outpatient diagnosis codes paired with fracture repair procedure codes. We computed age-standardized race/ethnicity-specific incidence rates and assessed trends in the rates over time using linear regression. On average, 821,475 women and 632,162 men were included in the analysis each year. Beneficiaries were predominantly white (88%), with African, Hispanic, and Asian Americans making up 8%, 1.5%, and 1.5% of the population, respectively. We identified 102,849, 4,119, 813, and 1,294 hip fractures in white, black, Asian, and Hispanic beneficiaries over the 10 years. A significant decreasing trend (p < 0.05) in hip fracture incidence from 2000-2001 to 2008-2009 was present in white women and men. Black and Asian beneficiaries experienced nonsignificant declines. Irrespective of gender, the largest rate of decline was seen in beneficiaries ≥75 years of age. The overall and age-specific rates of Hispanic women or men changed minimally over time. Hip fracture incidence rates continued to decline in recent years among white Medicare beneficiaries. Further research is needed to understand mechanisms responsible for declining rates in some and not others, as hip fractures continue to be a major problem among the elderly.