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Ganguli I, Mackwood MB, Yang CWW, Crawford M, Mulligan KL, O'Malley AJ, Fisher ES, Morden NE. Racial differences in low value care among older adult Medicare patients in US health systems: retrospective cohort study. BMJ 2023; 383:e074908. [PMID: 37879735 PMCID: PMC10599254 DOI: 10.1136/bmj-2023-074908] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE To characterize racial differences in receipt of low value care (services that provide little to no benefit yet have potential for harm) among older Medicare beneficiaries overall and within health systems in the United States. DESIGN Retrospective cohort study SETTING: 100% Medicare fee-for-service administrative data (2016-18). PARTICIPANTS Black and White Medicare patients aged 65 or older as of 2016 and attributed to 595 health systems in the United States. MAIN OUTCOME MEASURES Receipt of 40 low value services among Black and White patients, with and without adjustment for patient age, sex, and previous healthcare use. Additional models included health system fixed effects to assess racial differences within health systems and separately, racial composition of the health system's population to assess the relative contributions of individual patient race and health system racial composition to low value care receipt. RESULTS The cohort included 9 833 304 patients (6.8% Black; 57.9% female). Of 40 low value services examined, Black patients had higher adjusted receipt of nine services and lower receipt of 20 services than White patients. Specifically, Black patients were more likely to receive low value acute diagnostic tests, including imaging for uncomplicated headache (6.9% v 3.2%) and head computed tomography scans for dizziness (3.1% v 1.9%). White patients had higher rates of low value screening tests and treatments, including preoperative laboratory tests (10.3% v 6.5%), prostate specific antigen tests (31.0% v 25.7%), and antibiotics for upper respiratory infections (36.6% v 32.7%; all P<0.001). Secondary analyses showed that these differences persisted within given health systems and were not explained by Black and White patients receiving care from different systems. CONCLUSIONS Black patients were more likely to receive low value acute diagnostic tests and White patients were more likely to receive low value screening tests and treatments. Differences were generally small and were largely due to differential care within health systems. These patterns suggest potential individual, interpersonal, and structural factors that researchers, policy makers, and health system leaders might investigate and address to improve care quality and equity.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School and Brigham and Women's Hospital, Boston, MA, USA
| | - Matthew B Mackwood
- Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Ching-Wen Wendy Yang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Maia Crawford
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | | | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Elliott S Fisher
- Department of Community & Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Nancy E Morden
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
- UnitedHealthcare, Minnetonka, MN, USA
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Khusid E, Lui B, Tangel VE, Jiang SY, Oxford C, Abramovitz SE, Weinstein ER, White RS. Patient- and Hospital- Level Disparities in Severe Maternal Morbidity: a Retrospective Multistate Analysis, 2015-2020. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01763-7. [PMID: 37610646 DOI: 10.1007/s40615-023-01763-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/11/2023] [Accepted: 08/14/2023] [Indexed: 08/24/2023]
Abstract
The rate of severe maternal morbidity (SMM) in the United States (US) rose roughly 9% among all insured racial/ethnic groups between 2018 and 2020, disproportionately affecting racial and ethnic minority populations. Limited research on hospital-level factors and SMM found that even after adjusting for patient-level factors, women of all races delivering in high Black-serving delivery units had higher odds of SMM. Our retrospective cohort study augments the current understanding of multi-level racial/ethnic disparities in SMM by analyzing patient- and hospital- level factors using multistate data from 2015 to 2020. Because rises in SMM have been driven in part by an increase in blood transfusions, multivariable logistic regression models were employed to estimate the impact of patient- and hospital-level factors on the adjusted odds of experiencing any SMM, with and without blood transfusions, as well as blood transfusions alone. Our cohort consisted of 3,497,233 deliveries: 56,885 (1.63%) with any SMM, 16,070 (0.46%) with SMM excluding blood transfusion, and 45,468 (1.30%) with blood transfusions alone. We found that Black race, Hispanic ethnicity, and delivering at Black-serving delivery-units, both independently and interactively, increase the odds of any SMM with or without blood transfusions. Our findings illustrate the persistence of structural- and individual- level racial and ethnic disparities in maternal outcomes over time and emphasize the need for multi-level public policies to address racial/ethnic disparities in maternal healthcare.
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Affiliation(s)
- Elizabeth Khusid
- Weill Cornell Medical College, Weill Cornell Medicine, NY, New York, USA
| | - Briana Lui
- Weill Cornell Medical College, Weill Cornell Medicine, NY, New York, USA
| | - Virginia E Tangel
- Department of Anesthesiology, New York Presbyterian/Weill Cornell Hospital, 525 East 68th Street, M324, New York, NY, 10065, USA
| | - Silis Y Jiang
- Department of Anesthesiology, New York Presbyterian/Weill Cornell Hospital, 525 East 68th Street, M324, New York, NY, 10065, USA
| | - Corrina Oxford
- Department of Maternal and Fetal Medicine, New York-Presbyterian/Weill Cornell Medical Center, New York, NY, USA
| | - Sharon E Abramovitz
- Department of Anesthesiology, New York Presbyterian/Weill Cornell Hospital, 525 East 68th Street, M324, New York, NY, 10065, USA
| | - Eliana R Weinstein
- Department of Anesthesiology, New York Presbyterian/Weill Cornell Hospital, 525 East 68th Street, M324, New York, NY, 10065, USA
| | - Robert S White
- Department of Anesthesiology, New York Presbyterian/Weill Cornell Hospital, 525 East 68th Street, M324, New York, NY, 10065, USA.
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Hailu EM, Carmichael SL, Berkowitz RL, Snowden JM, Lyndon A, Main E, Mujahid MS. Racial/ethnic disparities in severe maternal morbidity: An intersectional lifecourse approach. Ann N Y Acad Sci 2022; 1518:239-248. [PMID: 36166238 PMCID: PMC11019852 DOI: 10.1111/nyas.14901] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Despite long-existing calls to address alarming racial/ethnic gaps in severe maternal morbidity (SMM), research that considers the impact of intersecting social inequities on SMM risk remains scarce. Invoking intersectionality theory, we sought to assess SMM risk at the nexus of racial/ethnic marginalization, weathering, and neighborhood/individual socioeconomic disadvantage. We used birth hospitalization records from California across 20 years (1997-2017, N = 9,806,406) on all live births ≥20 weeks gestation. We estimated adjusted average predicted probabilities of SMM at the combination of levels of race/ethnicity, age, and neighborhood deprivation or individual socioeconomic status (SES). The highest risk of SMM was observed among Black birthing people aged ≥35 years who either resided in the most deprived neighborhoods or had the lowest SES. Black birthing people conceptualized to be better off due to their social standing (aged 20-34 years and living in the least deprived neighborhoods or college graduates) had comparable and at times worse risk than White birthing people conceptualized to be worse off (aged ≥35 years and living in the most deprived neighborhoods or had a high-school degree or less). Our findings highlight the need to explicitly address structural racism as the driver of racial/ethnic health inequities and the imperative to incorporate intersectional approaches.
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Affiliation(s)
- Elleni M Hailu
- Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, California, USA
| | - Suzan L Carmichael
- Division of Neonatal & Developmental Medicine, Department of Pediatrics, and Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, USA
| | - Rachel L Berkowitz
- Department of Public Health and Recreation, College of Health and Human Sciences, San Jose State University, San Jose, California, USA
| | - Jonathan M Snowden
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, Oregon, USA
| | - Audrey Lyndon
- Rory Meyers College of Nursing, New York University, New York, New York, USA
| | - Elliott Main
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Mahasin S Mujahid
- Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, California, USA
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Abstract
PURPOSE OF REVIEW Healthcare disparities are health differences that adversely affect disadvantaged populations. In the United States, research shows that women of color, in particular Black and Hispanic women and their offspring, experience disproportionately higher mortality, severe maternal morbidity, and neonatal morbidity and mortality. This review highlights recent population health sciences and comparative effectiveness research that discuss racial and ethnic disparities in maternal and perinatal outcomes. RECENT FINDINGS Epidemiological research confirms the presence of maternal and neonatal disparities in national and multistate database analysis. These disparities are associated with geographical variations, hospital characteristics and practice patterns, and patient demographics and comorbidities. Proposed solutions include expanded perinatal insurance coverage, increased maternal healthcare public funding, and quality improvement initiatives/efforts that promote healthcare protocols and practice standardization. SUMMARY Obstetrical healthcare disparities are persistent, prevalent, and complex and are associated with systemic racism and social determinants of health. Some of the excess disparity gap can be explained through community-, hospital-, provider-, and patient-level factors. Providers and healthcare organizations should be mindful of these disparities and strive to promote healthcare justice and patient equity. Several solutions provide promise in closing this gap, but much effort remains.
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