Disparities in the Prevalence of Unmet Needs and Their Consequences Among Black and White Older Adults

State home and community-based services expenditures and unmet care needs in the United States: Has everyone benefitted equally?

OBJECTIVE

To test whether the impacts of Medicaid's Home and Community-Based Services (HCBS) expenditures have been equitable.

DATA SOURCES AND STUDY SETTING

This is a secondary data analysis. We linked annual data on state-level Medicaid HCBS expenditures with individual data from U.S. Health and Retirement Study (HRS; 2006-2016).

STUDY DESIGN

We evaluated the association between state-level HCBS expenditure quartiles and the risk of experiencing challenges in basic or instrumental activities of daily living (I/ADLs) without assistance (unmet needs for care). We fitted generalized estimating equations (GEE) with a Poisson distribution, log link function, and an unstructured covariance matrix. We controlled demographics, time, and place-based fixed effects and estimated models stratified by race and ethnicity, gender, and urbanicity. We tested the robustness of results with negative controls.

DATA COLLECTION/EXTRACTION METHODS

Our analytic sample included HRS Medicaid beneficiaries, aged 55+, who had difficulty with ≥1 I/ADL (n = 2607 unique respondents contributing 4719 person-wave observations).

PRINCIPAL FINDINGS

Among adults with IADL difficulty, higher quartiles of HCBS expenditure (vs. the lowest quartile) were associated with a lower overall prevalence of unmet needs for care (e.g., Prevalence Ratio [PR], Q4 vs. Q1: 0.91, 95% CI: 0.84-0.98). This protective association was concentrated among non-Hispanic white respondents (Q4 vs. Q1: 0.82, 95% CI: 0.73-0.93); estimates were imprecise for Hispanic individuals and largely null for non-Hispanic Black participants. We found no evidence of heterogeneity by gender or urbanicity. Negative control robustness checks indicated that higher quartiles of HCBS expenditure were not associated with (1) the risk of reporting I/ADL difficulty among 55+ Medicaid beneficiaries, and (2) the risk of unmet care needs among non-Medicaid beneficiaries.

CONCLUSION

The returns to higher state-level HCBS expenditures under Medicaid for older adults with I/ADL disability do not appear to have been equitable by race and ethnicity.

Race/Ethnicity, Nativity, and Gender Disparities in Unmet Care Needs Among Older Adults in the United States

BACKGROUND AND OBJECTIVES

Although disparities in disability and the unequal distribution of care resources are widely discussed in the literature, there has been less research on disparities in experiencing unmet care needs among older adults. This study aims to investigate how unmet care needs are unevenly distributed across social groups with various intersecting identities, such as race/ethnicity, nativity, and gender, although considering their care needs and care networks, drawing on the conceptual framework of the pathway to unmet needs.

RESEARCH DESIGN AND METHODS

The data for this study came from the National Health and Aging Trends Study (2011-2018), and the study sample consisted of 7,061 Medicare beneficiaries who needed assistance with daily activities. Questions about unmet care needs were in the form of consequences related to difficulty or lack of help with daily activities. Mixed-effects negative binomial regression models were used to predict rates of unmet needs.

RESULTS

Older adults of color, especially women, experienced higher rates of unmet care needs compared with their White and male counterparts. Although Black-White and gender differences in unmet needs were mostly explained by unequal exposures to care needs and differential care networks, Hispanic women and foreign-born Hispanic men were still at a disadvantage even after adjusting for these covariates.

DISCUSSION AND IMPLICATIONS

These results emphasize the importance of adopting an intersectional approach to enhance the quality of long-term services and support for older adults facing social disadvantages.

Ageing with Parkinson's: Identification of Personal Needs in the Northern Spanish Context

As individuals diagnosed with Parkinson's disease enter older age, the myriad challenges and complications associated with this condition tend to escalate. Hence, there is a critical necessity to comprehensively discern the perceived needs of these individuals, along with their proposed remedies and essential support requisites. Additionally, understanding the perspectives of their families becomes imperative to formulate tailored interventions aimed at enhancing their overall development, progression, and quality of life. The study's main objective is to assess the perceived needs of individuals with PD and their family members, propose necessary solutions, and suggest future perspectives. The study encompassed a cohort of 268 participants, comprising 179 individuals diagnosed with Parkinson's disease and 89 of their relatives. A meticulously designed structured interview instrument consisting of 93 items was employed to assess various domains encompassing perceived needs, institutional support mechanisms, essential solutions, and future anticipations. Results: Statistically significant differences were found in health resources, social services resources, obstacles, solutions, and future outlook, with higher mean values from the relatives. Conclusions: The results highlight the most concerning needs in this context. Specifically, those needs related to health resources, social services resources, and future outlook present the greatest differences between the two subsamples, with the family members perceiving more needs. This alignment extended to both the categorization of unmet needs and the requisite solutions envisioned to address them. Suggested improvements include a sociosanitary strategy, stakeholder involvement, and prioritizing flexible home assistance to support older individuals with PD and their families.

Frailty as a predictor of mortality: a comparative cohort study of older adults in Costa Rica and the United States

BACKGROUND

Frailty is a common condition among older adults that results from aging-related declines in multiple systems. Frailty increases older adults' vulnerability to negative health outcomes, including loss of mobility, falls, hospitalizations, and mortality. The aim of this study is to examine the association between frailty and mortality in older adults from Costa Rica and the United States.

METHODS

This prospective cohort study uses secondary nationally-representative data of community-dwelling older adults from the Costa Rican Longevity and Healthy Aging Study (CRELES, n = 1,790) and the National Health & Aging Trends Study (NHATS, n = 6,680). Frailty status was assessed using Physical Frailty Phenotype, which includes the following five criteria: shrinking, exhaustion, low physical activity, muscle weakness, and slow gait. We used Cox proportional hazard models to examine the association between frailty and all-cause mortality, including sociodemographic characteristics and health behaviors as covariates in the models. Mortality follow-up time was right censored at 8 years from the date at baseline interview.

RESULTS

The death hazard for frail compared to non-frail older adults was three-fold in Costa Rica (HR = 3.14, 95% CI: 2.13-4.62) and four-fold in the White US (HR = 4.02, 95% CI: 3.04-5.32). Older age, being male, and smoking increased mortality risk in both countries. High education was a protective factor in the US, whereas being married/in union was a protective factor in Costa Rica. In the US, White older adults had a lower risk of death compared to all other races and ethnicities.

CONCLUSIONS

Results indicate that frailty can have a differential impact on mortality depending on the country. Access to universal health care across the life course in Costa Rica and higher levels of stress and social isolation in the US may explain differences observed in end-of-life trajectories among frail older adults.

The Role of Trust in Older Adult Service Provision at the Onset of the COVID-19 Pandemic

The COVID-19 pandemic caused near immediate service delivery adaptation among social service and healthcare sectors. Findings from in-depth interviews with 45 senior leaders of social services and healthcare organizations serving older adults in Washington State elucidate the role of trust in service provision at the onset of the pandemic. First, a history of trust facilitated service adaptation. Intentional outreach, programs, and culturally responsive services sustained trust with service recipients. Providing services and information in an older adult's preferred language built trust. Community networks facilitated and reflected trust between organizations and older adults. Finally, mistrust was prevalent for clients who perceived a high risk of experiencing negative consequences from accessing services. Our findings support the need for culturally and linguistically diverse services. To improve trust, the aging network should strengthen and expand partnerships with community-based organizations who have established trust through history, intentionality, and relevance to their service populations..

Patterns of Unmet Needs With Assistance for Self-Care Activities at the End of Life by Place of Death Among Older Adults

Older Americans experience adverse consequences linked to inadequate assistance with self-care activities. These unmet care needs increase risk of hospitalization, institutionalization, and morbidity. While a growing body of research has focused on disparities in unmet care needs and place of death outcomes among older adults separately, less is known about the intersection between the two: place of death and unmet care needs at the end of life. Therefore, this study utilized data from the National Health & Aging Trends Study (NHATS) to examine patterns of place of death and unmet care needs outcomes among older adults to identify disparities in care and inform policies and programs. We conducted weighted bivariate analyses and multivariate logistic regression models using appropriate survey weights. Findings suggest more than half of older adults experienced an unmet need at the end of their lives and increasing rates of unmet needs are experienced by older adults who died in hospitals. Older adults receiving hospice care were also found to have less unmet needs at the end of their lives. Given the well-documented consequences of unmet needs with self-care activities, ongoing research is needed to better inform policies and programs that provide assistance and support to older adults with their self-care activities during their end of lives.

Loneliness Among Black/African American Adults Living with HIV: Sociodemographic and Psychosocial Correlates and Implications for Adherence

Loneliness, an emerging public health problem, is higher among people living with HIV and is associated with negative health outcomes. Black/African Americans have a high burden of HIV, and little is known about the characteristics of loneliness among Black adults living with HIV; therefore, this study sought to understand the sociodemographic and psychosocial correlates of Black adults living with HIV who are lonely and the implications of loneliness for their health outcomes. A sample of 304 Black adults living with HIV (73.8% sexual minority men) in Los Angeles County, CA, USA, completed the survey items assessing sociodemographic and psychosocial characteristics, social determinants of health, health outcomes, and loneliness. Antiretroviral therapy (ART) adherence was assessed electronically with the medication event monitoring system. Bivariate linear regressions analysis showed higher loneliness scores among those with higher levels of internalized HIV stigma, depression, unmet needs, and discrimination related to HIV serostatus, race, and sexual orientation. In addition, participants who were married or living with a partner, had stable housing, and reported receiving more social support had lower levels of loneliness. In multivariable regression models controlling for correlates of loneliness, loneliness was found to be a significant independent predictor of worse general physical health, worse general mental health, and greater depression. Loneliness was marginally associated with lower ART adherence. Findings suggest that Black adults living with HIV, who experience multiple intersectional stigmas, require targeted interventions and resources.

Association Between Race and Receipt of Home- and Community-Based Rehabilitation After Traumatic Brain Injury Among Older Medicare Beneficiaries

Importance

Non-Hispanic Black (hereafter Black) patients with traumatic brain injury (TBI) experience worse long-term outcomes and residual disability compared with non-Hispanic White (hereafter White) patients. Receipt of appropriate rehabilitation can improve function among older adults after TBI.

Objective

To assess the association between race and receipt of home- and community-based rehabilitation among a nationally representative sample of older Medicare beneficiaries with TBI.

Design, Setting, and Participants

This cohort study analyzed a random sample of Medicare administrative claims data for community-dwelling Medicare beneficiaries aged 65 years or older who were hospitalized with a primary diagnosis of TBI and discharged alive to a nonhospice setting from 2010 through 2018. Claims data for Medicare beneficiaries of other races and ethnicities were excluded due to the small sample sizes within each category. Data were analyzed January 21 to August 30, 2022.

Exposures

Black or White race.

Main Outcomes and Measures

Monthly use rates of home-based or outpatient rehabilitation were calculated over the 6 months after discharge from the hospital. The denominator for rate calculations accounted for variation in length of hospital and rehabilitation facility stays and loss to follow-up due to death. Rates over time were modeled using generalized estimating equations, controlling for TBI acuity, demographic characteristics, comorbidities, and socioeconomic factors.

Results

Among 19 026 Medicare beneficiaries (mean [SD] age, 81.6 [8.1] years; 10 781 women [56.7%]; and 994 Black beneficiaries [5.2%] and 18 032 White beneficiaries [94.8%]), receipt of 1 or more home health rehabilitation visits did not differ by race (Black vs White, 47.4% vs 46.2%; P = .46), but Black beneficiaries were less likely to receive 1 or more outpatient rehabilitation visits compared with White beneficiaries (3.4% vs 7.1%; P < .001). In fully adjusted regression models, Black beneficiaries received less outpatient therapy over the 6 months after TBI (rate ratio, 0.60; 95% CI, 0.38-0.93). However, Black beneficiaries received more home health rehabilitation therapy over the 6 months after TBI than White beneficiaries (rate ratio, 1.15; 95% CI, 1.00-1.32).

Conclusions and Relevance

This cohort study found relative shifts in rehabilitation use, with markedly lower outpatient therapy use and modestly higher home health care use among Black patients compared with White patients with TBI. These disparities may contribute to reduced functional recovery and residual disability among racial and ethnic minority groups. Additional studies are needed to assess the association between the amount of outpatient rehabilitation care and functional recovery after TBI in socioeconomically disadvantaged populations.

A systematic review and meta-analysis of unmet needs for healthcare and long-term care among older people

BACKGROUND

The absolute number of older individuals needing medical care and long-term care (LTC) is increasing globally due to the growing ageing population. However, it is uncertain who and what proportion of the population has access to care. Therefore, a systematic review and meta-analysis of the prevalence and reasons for unmet needs for healthcare and long-term care among older people, 65 years old and above, across countries was conducted.

METHODS

An information specialist performed a comprehensive search of four major databases (PubMed, EMBASE, Web of Science, and CINAHL) from inception to June 2020 without restrictions on language and date. We did random-effects meta-analysis to obtain pooled prevalence. We stratified the meta-analysis by reasons for unmet need categorized by barrier dimension (availability, accessibility, affordability, and acceptability), survey year, geographic location, and socio-demographic characteristics of the older individual.

RESULTS

After screening 3912 articles, we included 101 studies published between 1996 and 2020. Of the 101 studies, 87 studies reported unmet healthcare needs and 14 studies reported unmet LTC needs. Overall, 10.4% (95% CI, 7.3-13.9) of the older population had unmet needs for healthcare. The common reasons for unmet healthcare needs were cost of treatment, lack of health facilities, lack of/conflicting time, health problem not viewed as serious, and mistrust/fear of provider. A significant variation in pooled prevalence of unmet healthcare needs due to cost was found by gender (male [10.9, 95% CI, 8.9-13.1] vs female [14.4, 95% CI, 11.8-17.3]), educational level (primary or less [13.3, 95% CI, 9.6-17.6] vs higher [7.5, 95% CI, 5.9-9.3]), self-reported health (poor [23.2, 95% CI, 18.8-27.8] vs good [4.4, 95% CI, 3.4-5.5]), insurance status (insured [9.0, 95% CI, 7.5-10.6] vs uninsured [27.7, 95% CI, 24.0-31.5]), and economic status of population (poorest [28.2, 95% CI, 14.1-44.9] vs richest [7.1, 95% CI, 3.8-11.3]). One in four (25.1, 95% CI, 17.1-34.2) older people had unmet needs in LTC. Rural residents had a higher prevalence of unmet needs in LTC compared to their urban counterparts.

CONCLUSION

With the population ageing globally, it is necessary to improve access to health care and LTC for older people. Ensuring affordability of health services, reducing geographical barriers, and improving acceptability, will be critical in reducing unmet need. Unmet needs for healthcare were concentrated in population with no education, poor economic group, outpatient health facility user, and uninsured group. With education and economic-based inequalities at the forefront, all countries should focus on improving access to health services by reducing the burden related to healthcare costs.

Access to Long-Term Care for Minority Populations: A Systematic Review

It has been shown that there is disparity in access to long-term care and other services for minority populations. This study assessed long-term care access among older individuals belonging to minority populations including visible, ethnocultural, linguistic, and sexual minorities. Barriers and facilitators influencing admission were identified and evaluated.A search for articles from 10 databases published between January 2000 and January 2021 was conducted. Included studies evaluated factors affecting minority populations' admission to long-term care, and non-residents' perceptions of future admission. This review was registered with PROSPERO: CRD42018038662. Sixty included quantitative and qualitative studies, ranging in quality from fair to excellent. Findings suggest minority status is associated with reduced admission to long-term care, controlling for confounding variables. Barriers identified include discordant language, fear of discrimination, lack of information, and family obligations. Findings suggest that minority populations experienced barriers accessing long-term care and had unmet cultural and language needs while receiving care in this setting.

Factors associated with unmet need for support to maintain independence in later life: a systematic review of quantitative and qualitative evidence

BACKGROUND

populations are considered to have an 'unmet need' when they could benefit from, but do not get, the necessary support. Policy efforts to achieve equitable access to long-term care require an understanding of patterns of unmet need. A systematic review was conducted to identify factors associated with unmet need for support to maintain independence in later life.

METHODS

seven bibliographic databases and four non-bibliographic evidence sources were searched. Quantitative observational studies and qualitative systematic reviews were included if they reported factors associated with unmet need for support to maintain independence in populations aged 50+, in high-income countries. No limits to publication date were imposed. Studies were quality assessed and a narrative synthesis used, supported by forest plots to visualise data.

FINDINGS

forty-three quantitative studies and 10 qualitative systematic reviews were included. Evidence across multiple studies suggests that being male, younger age, living alone, having lower levels of income, poor self-rated health, more functional limitations and greater severity of depression were linked to unmet need. Other factors that were reported in single studies were also identified. In the qualitative reviews, care eligibility criteria, the quality, adequacy and absence of care, and cultural and language barriers were implicated in unmet need.

CONCLUSIONS

this review identifies which groups of older people may be most at risk of not accessing the support they need to maintain independence. Ongoing monitoring of unmet need is critical to support policy efforts to achieve equal ageing and equitable access to care.

White and Black Differences in Perceived Access to Health and Community Services and Self-Rated Health in an Age-Friendly Community Assessment

OBJECTIVES

This study sought to identify the race differences in perceived access to health and community services and self-rated health (SRH) among White and Black older adult participants of an age-friendly community assessment.

METHODS

Responses (n = 313) to a baseline assessment of Columbus, Ohio, residents aged ≥50 years were analyzed.

RESULTS

Significant differences were found between White and Black older adults regarding SRH, with Black older adults reporting lower SRH. Black older adults reported significantly lower perceived access to 11 out of the 13 health and community services. There were no significant differences by race regarding ratings of Columbus and personal neighborhoods as a place for people to live as they age. Regression analyses found income was a significant predictor of SRH for both White and Black older adults.

DISCUSSION

Opportunities to increase perceived access and knowledge of health and community services for older adults through targeted, equitable interventions are warranted.

Demographic Characteristics Driving Disparities in Receipt of Long-term Services and Supports in the Community Setting

BACKGROUND

Research suggests that growth in Black and Hispanic (minority) older adults' nursing home (NH) use may be the result of disparities in access to community-based and alternative long-term services and supports (LTSS).

OBJECTIVE

We aimed to determine whether minority groups receiving care in NHs versus the community had fewer differences in their functional needs compared with the differences in nonminority older adults, suggesting a disparity.

METHODS

We identified respondents aged 65 years or above with a diagnosis of Alzheimer disease or dementia in the 2016 Health and Retirement Study who reported requiring LTSS help. We performed unadjusted analyses to assess the difference in functional need between community and NH care. Functional need was operationalized using a functional limitations score and 6 individual activities of daily living. We compared the LTSS setting for minority older adults to White older adults using difference-in-differences.

RESULTS

There were 186 minority older adults (community=75%, NH=25%) and 357 White older adults (community=50%, NH=50%). Between settings, minority older adults did not differ in education or marital status, but were younger and had greater income in the NH versus the community. The functional limitations score was higher in NHs than in the community for both groups. Functional needs for all 6 activities of daily living for the minority group were greater in NHs compared with the community.

CONCLUSION

Functional need for minority older adults differed by setting while demographics varied in unexpected ways. Factors such as familial and financial support are important to consider when implementing programs to keep older adults out of NHs.

Unmet care needs of older people: A scoping review

The aim was to synthesize the findings of empirical research about the unmet nursing care needs of older people, mainly from their point of view, from all settings, focusing on (1) methodological approaches, (2) relevant concepts and terminology and (3) type, nature and ethical issues raised in the investigations. A scoping review after Arksey and O'Malley. Two electronic databases, MEDLINE/PubMed and CINAHL (from earliest to December 2019) were used. Systematic search protocol was developed using several terms for unmet care needs and missed care. Using a three-step retrieval process, peer-reviewed, empirical studies concerning the unmet care needs of older people in care settings, published in English were included. An inductive content analysis was used to analyse the results of the included studies (n = 53). The most frequently used investigation method was the questionnaire survey seeking the opinions of older people, informal caregivers or healthcare professionals. The unmet care needs identified using the World Health Organization classification were categorized as physical, psychosocial and spiritual, and mostly described individuals' experiences, though some discussed unmet care needs at an organizational level. The ethical issues raised related to the clinical prioritization of tasks associated with failing to carry out nursing care activities needed. The unmet care needs highlighted in this review are related to poor patient outcomes. The needs of institutionalized older patients remain under-diagnosed and thus, untreated. Negative care outcomes generate a range of serious practical issues for older people in care institutions, which, in turn, raises ethical issues that need to be addressed. Unmet care needs may lead to marginalization, discrimination and inequality in care and service delivery. Further studies are required about patients' expectations when they are admitted to hospital settings, or training of nurses in terms of understanding the complex needs of older persons.

Impact of Perceived Racism on Healthcare Access Among Older Minority Adults

INTRODUCTION

Older minority individuals are less likely to receive adequate health care than their white counterparts. This study investigates whether perceived racism is associated with delayed/forgone care among minority older adults, and whether poor doctor communication mediates this relationship.

METHODS

Study cohort consisted of minority participants, aged ≥65 years, in the 2015 California Health Interview Survey (N=1,756). Authors obtained data in November 2017, and statistical analyses were performed from February to April 2018. Multivariable logistic regression analyses were conducted with relevant covariates, including insurance coverage, years living in the U.S., and language. A mediation analysis was also performed.

RESULTS

Among minority older individuals, perceived racism was significantly associated with delayed/forgone care (AOR=3.92, 95% CI=1.38, 11.15, p=0.010). Poor doctor communication significantly and partially mediated the relationship (AOR=3.64, 95% CI=1.30, 10.21, p=0.014), accounting for 9.9% of the total effect.

CONCLUSIONS

Perceived racism may contribute to health disparities for older minority individuals in part through doctors communicating messages that discourage adequate utilization of health care. Future research should explore culturally sensitive communication skills that reduce this barrier to receiving adequate health care.