Background: Dementia is often underdiagnosed, and self-reported data suggest that this problem may be more common among racial and ethnic minority groups. This study examined racial and ethnic disparities in the timeliness in which individuals receive a formal dementia diagnosis.

OBJECTIVES:To examine racial and ethnic differences in knowledge about one's dementia status DESIGN: Prospective cohort study SETTING: 2000-2014 Health and Retirement Study PARTICIPANTS: Our sample included 8,686 person-wave observations representing 4,065 unique survey participants age ≥70 with dementia, as identified by a well-validated statistical prediction model based on individual demographic and clinical characteristics. MEASUREMENTS: Primary outcome measure was knowledge of one's dementia status as reported in the survey. Patient characteristics included race/ethnicity, age, gender, survey year, cognition, function, comorbidity, and whether living in a nursing home.RESULTS: Among subjects identified as having dementia by the prediction model, 43.5%-50.2%, depending on the survey year, reported that they were informed of the dementia status by their doctor. This proportion was lower among Hispanics (25.9%-42.2%) and non-Hispanic blacks (31.4%-50.5%) than among non-Hispanic Whites (47.7%-52.9%). Our fully-adjusted regression model indicated lower dementia awareness among non-Hispanic blacks (OR=0.74 95% CI: 0.58-0.94) and Hispanics (OR=0.60; 95% CI: 0.43-0.85), compared to non-Hispanic whites. Having more IADL limitations (OR=1.65, 95% CI: 1.56-1.75) and living in a nursing home (OR=2.78, 95% CI: 2.32-3.32) were associated with increased odds of subjects reporting being told about dementia by a physician.

BACKGROUND: Low-value care, typically defined as health services that provide little or no benefit, has potential to cause harm, incur unnecessary costs, and waste limited resources. Although evidence-based guidelines identifying low-value care have increased, the guidelines differ in the type of evidence they cite to support recommendations against its routine use. OBJECTIVE: We examined the evidentiary rationale und e r l y i n g r e c o m m e n d a t i o n s a g a i n s t l ow -v a l u e interventions. DESIGN: We identified 1167 "low-value care" recommendations across five US organizations: the US Preventive Services Task Force (USPSTF), the "Choosing Wisely" Initiative,

Background Dementia is often underdiagnosed, and self‐reported data suggest that this problem may be more common among racial and ethnic minority groups. This study examined racial and ethnic disparities in the timeliness in which individuals receive a formal dementia diagnosis. Method This analysis used eight waves of US national surveys from 2000‐2014 Health and Retirement Study, linked with Medicare and Medicaid claims. We identified study participants age ≥70 with dementia using a well‐validated statistical model based on individual’s age, gender, education, cognition, and functional limitations. We assessed the proportion of patients not receiving a coded diagnosis of dementia in their claims by the time the prediction model classified them as having dementia. We used logistic regression models to compare the likelihood of missed or delayed dementia diagnoses in claims by race and ethnicity, adjusting for patient characteristics. We analyzed dementia severity, measured by cognition (TICS scores for self‐respondents; IQCODE scores for proxy‐respondents) and functional limitations, at the time of a dementia diagnosis documented in claims, by race/ethnicity. All analyses adjusted for sampling weights. Result Our sample included 3,966 older adults with dementia. Forty‐two percent had a missed or delayed dementia diagnosis in their claims. This proportion was higher among non‐Hispanic blacks and Hispanics than among non‐Hispanic whites (46% and 54% vs. 41%, p<0.001). Logistic regression model indicated more frequent missed/delayed dementia diagnoses among non‐Hispanic blacks (OR=1.27; 95% CI: 1.05‐1.53) and Hispanics (OR=1.83; 95% CI: 1.43‐2.35), compared to non‐Hispanic whites. Over the study period, 76% had a dementia diagnosis documented in their claims. At the time of diagnosis, non‐Hispanic blacks and Hispanics had poorer cognitive function and more functional impairments, compared to non‐Hispanic whites. Conclusion Non‐Hispanic blacks and Hispanics may experience missed or delayed diagnoses of dementia more often than non‐Hispanic whites. When they are diagnosed, non‐Hispanic blacks and Hispanics may have more advanced dementia compared to non‐Hispanic whites. Public health efforts such as the Brain Health Initiative should tailor campaigns to different ethnoracial groups when promoting early diagnosis of dementia. The medical community should implement provider training on culturally competent dementia care and improve documentation of dementia diagnostic findings in health insurance claims.

NCT00948129; Results.

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ImportanceDelivering low-value care can lead to unnecessary follow-up services and associated costs, and such care cascades have not been well examined in common clinical scenarios.ObjectiveTo evaluate the utilization and costs of care cascades of prostate-specific antigen (PSA) tests for prostate cancer screening, as the routine use of which among asymptomatic men aged 70 years and older is discouraged by multiple guidelines.Design, Setting, and ParticipantsThis cross-sectional study included men aged 70 years and older without preexisting prostate conditions enrolled in a Medicare Advantage plan during January 2016 to December 2018 with at least 1 outpatient visit. Medical billing claims data from the deidentified OptumLabs Data Warehouse were used. Data analysis was conducted from September 2020 to August 2021.ExposuresAt least 1 claim for low-value PSA tests for prostate cancer screening during the observation period.Main Outcomes and MeasuresUtilization of and spending on low-value PSA cancer screening and associated care cascades and the difference in overall health care utilization and spending among individuals receiving low-value PSA cancer screening vs those who did not, adjusting for observed characteristics using inverse probability of treatment weighting.ResultsOf 995 442 men (mean [SD] age, 78.0 [5.6] years) aged 70 years or older in a Medicare Advantage plan included in this study, 384 058 (38.6%) received a low-value PSA cancer screening. Utilization increased for each subsequent cohort from 2016 to 2018 (49 802 of 168 951 [29.4%] to 134 404 of 349 228 [38.5%] to 199 852 of 477 203 [41.9%]). Among those receiving initial low-value PSA cancer screening, 241 188 of 384 058 (62.8%) received at least 1 follow-up service. Repeated PSA testing was the most common, and 27 268 (7.1%) incurred high-cost follow-up services, such as imaging, radiation therapy, and prostatectomy. Utilization and spending associated with care cascades also increased from 2016 to 2018. For every $1 spent on a low-value PSA cancer screening, an additional $6 was spent on care cascades. Despite avoidable care cascades, individuals who received low-value PSA cancer screening were not associated with increased overall health care utilization and spending during the 1-year follow-up period compared with an unscreened population.Conclusions and RelevanceIn this cross-sectional study, low-value PSA tests for prostate cancer screening remained prevalent among Medicare Advantage plan enrollees and were associated with unnecessary expenditures due to avoidable care cascades. Innovative efforts from clinicians and policy makers, such as payment reforms, to reduce initial low-value care and avoidable care cascades are warranted to decrease harm, enhance equity, and improve health care efficiency.

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