Background Racial and ethnic minorities generally receive fewer medical interventions than Whites, but racial and ethnic patterns in Medicare expenditures and interventions may be quite different at life's end. Methods Based on a random, stratified sample of Medicare decedents (n=158,780) in 2001, we used regression to relate differences in age, sex, cause of death, total morbidity burden, geography, life-sustaining interventions (e.g., ventilators), and hospice to racial/ethnic differences in Medicare expenditures in the last 6 months of life. Results In the final 6 months of life, costs for Whites average $20,166; Blacks, $26,704 (32% more); Hispanics, $31,702 (57% more). Similar differences exist within sexes, age groups, all causes of death, all sites of death, and within similar geographic areas. Differences in age, sex, cause of death, total morbidity burden, geography, socioeconomic status, and hospice account for 53% and 63% of the higher costs for Blacks and Hispanics respectively. While Whites use hospice most frequently (Whites 26%, Blacks 20%, and Hispanics 23%), this affects racial and ethnic differences in end-of-life expenditures only minimally. However, fully 85% of the observed higher costs for non-Whites are accounted for after additionally modeling their greater end-of-life use of the ICU and various intensive procedures (such as, gastrostomies, used by 10.5% of Blacks, 9.1% of Hispanics, 4.1% of Whites). Conclusions At life's end, Black and Hispanic decedents have substantially higher costs than Whites. Over half of this is related to geographic, socio-demographic and morbidity differences. Strikingly greater use of life-sustaining interventions accounts for most of the rest.

BackgroundWe examined the quality of adult epilepsy care using the Quality Indicators in Epilepsy Treatment (QUIET) measure, and variations in quality based on the source of epilepsy care.MethodsWe identified 311 individuals with epilepsy diagnosis between 2004 and 2007 in a tertiary medical center in New England. We abstracted medical charts to identify the extent to which participants received quality indicator (QI) concordant care for individual QI's and the proportion of recommended care processes completed for different aspects of epilepsy care over a two year period. Finally, we compared the proportion of recommended care processes completed for those receiving care only in primary care, neurology clinics, or care shared between primary care and neurology providers.ResultsThe mean proportion of concordant care by indicator was 55.6 (standard deviation = 31.5). Of the 1985 possible care processes, 877 (44.2%) were performed; care specific to women had the lowest concordance (37% vs. 42% [first seizure evaluation], 44% [initial epilepsy treatment], 45% [chronic care]). Individuals receiving shared care had more aspects of QI concordant care performed than did those receiving neurology care for initial treatment (53% vs. 43%; X2 = 9.0; p = 0.01) and chronic epilepsy care (55% vs. 42%; X2 = 30.2; p < 0.001).ConclusionsSimilar to most other chronic diseases, less than half of recommended care processes were performed. Further investigation is needed to understand whether a shared-care model enhances quality of care, and if so, how it leads to improvements in quality.

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Overall, PPVs were moderate for most of the PSIs. Implementing POA codes and using more specific ICD-9-CM codes would improve their validity. Our results suggest that additional coding improvements are needed before the PSIs evaluated herein are used for hospital reporting or pay for performance.

Objective-To estimate national total knee arthroplasty (TKA) rates by economic factors, and the extent to which differences in insurance coverage, income, and assets contribute to racial and ethnic disparities in TKA use. Data Source-US longitudinal Health and Retirement Study survey data for the elderly and nearelderly (biennial rounds 1994-2004) from the Institute of Social Research, University of Michigan.Study Design-The outcome is dichotomous, whether the respondent received first TKA in the previous 2 years. Longitudinal, random-effects logistic regression models are used to assess associations with lagged economic indicators.Sample-Sample was 55,469 person-year observations from 18,439 persons; 663, with first TKA.Results-Racial/ethnic disparities in TKA were more prominent among men than women. For example, relative to white women, odds ratios (ORs) were 0.94, 0.46, and 0.79, for white, black, and Hispanic men, respectively (P < 0.05 for black men). After adjusting for economic factors, racial/ ethnic differences in TKA rates for women essentially disappeared, while the deficit for black men remained large. Among Medicare-enrolled elderly, those with supplemental insurance may be more likely to have first TKA compared with those without it, whether the supplemental coverage was private [OR: 1.27; 95% confidence interval (CI): 0.82-1.96] or Medicaid (OR: 1.18; 95% CI: 0.93-1.49). Among the near-elderly (age 47-64), compared with the privately insured, the uninsured were less likely (OR: 0.61; 95% CI: 0.40-0.92) and those with Medicaid more likely (OR: 1.53; 95% CI: 1.03-2.26) to have first TKA.Conclusions-Limited insurance coverage and financial constraints explain some of the racial/ ethnic disparities in TKA rates.Total knee arthroplasty (TKA) is increasingly common with over 431,000 procedures performed nationwide in 2004. 1 For persons with severe and potentially disabling osteoarthritis, TKA is "efficacious and cost-effective …[it] relieves pain and reduces functional disability." 2 As the US population ages, growth in TKAs is expected to accelerate. A study of Canadians aged 55 or older concluded that those with less education and lower income were more likely to need TKA and similarly willing to undergo TKA as those with more education or income. 20 To the extent that these findings apply to the United States, lower TKA utilization among minorities with lower SES is not necessarily due to unwillingness to undergo TKA.A related study of disparities in joint (knee and hip) replacement based on a nationally representative (US) longitudinal survey sample of 6159 Medicare-enrolled adults (age 69 or older) found that those with supplementary Medigap coverage were more likely to have a joint replacement compared with those without. 21 The apparent difference with Skinner et al 6 may be due to the more detailed individual-level financial and insurance coverage measures in Dunlop et al. 21 Although the data used in this study are from the same survey source [Health and Retirement Study (HRS)] as ...

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Key PointsQuestionAre racial/ethnic minorities who use emergency medical services transported to the same emergency department as white residents living in the same zip code?FindingsIn this cohort study of 864 750 Medicare enrollees from 4175 zip codes, the proportion of white patients transported to the reference (or most frequent) emergency department destination was high (61.3%), compared with the proportion of black patients (difference of −5.3%) and Hispanic patients (difference of −2.5%).MeaningThis study suggests that emergency department destination is substantially different on the basis of the race/ethnicity of patients living in the same zip code.

Background The 2006 Massachusetts health reform substantially decreased uninsurance rates. Yet, little is known about the reform’s impact on actual healthcare utilization among poor and minority populations, particularly for receipt of inpatient surgical procedures that are commonly initiated by outpatient physician referral. Methods Using discharge data on MA hospitalizations for 21 months preceding and following health reform implementation (7/1/2006 – 12/31/2007), we identified all non-obstetrical major therapeutic procedures for patients aged ≥ 40 and for which ≥70 percent of hospitalizations were initiated by outpatient physician referral. Stratifying by race/ethnicity and patient residential zip code median (area) income, we estimated pre- and post-reform procedure rates, and their changes, for those aged 40–64 (non-elderly), adjusting for secular changes unrelated to reform by comparing to corresponding procedure rate changes for those aged >= 70 (elderly), whose coverage (Medicare) was not affected by reform. Results Overall increases in procedure rates (among 17 procedures identified) between pre- and post-reform periods were higher for non-elderly low area income (8%, p=0.04) and medium area income (8%, p<0.001) cohorts than for the high area income cohort (4%); and for Hispanics and Blacks (23% and 21% respectively; p values <0.001) than for Whites (7%). Adjusting for secular changes unrelated to reform, post-reform increases in procedure utilization among non-elderly were: by area income, low=13% (95% CI=[9%, 17%]), medium=15% ([6%, 24%]) and high=2% ([−3%, 8%]), and by race/ethnicity, Hispanics=22% ([5%, 38%]), Blacks=5% ([−20%, 30%]) and Whites=7% ([5%, 10%]). Conclusions Post-reform use of major inpatient procedures increased more among non-elderly lower and medium area income populations, Hispanics, and whites, suggesting potential improvements in access to outpatient care for these vulnerable subpopulations.