Disparities In Use Research Articles

Rural vs Urban Residence Affects Risk-Appropriate Colorectal Cancer Screening

Little is known about the effects of geographic factors, such as rural vs urban residence and travel time to colonoscopy providers, on risk-appropriate use of colorectal cancer (CRC) screening in the general population. We evaluated the effects of geographic factors on adherence to CRC screening and differences in screening use among familial risk groups. We analyzed data from the 2010 Utah Behavior Risk Factor Surveillance System, which included state-added questions on familial CRC. By using multiple logistic regression models, we assessed the effects of rural vs urban residence, travel time to the nearest colonoscopy provider, and spatial accessibility of providers on adherence to risk-appropriate screening guidelines. Study participants (n = 4260) were respondents aged 50 to 75 years. Sixty-six percent of the sample adhered to risk-appropriate CRC screening guidelines, with significant differences between urban and rural residents (68% vs 57%, respectively; P < .001) across all familial risk groups. Rural residents were less likely than urban dwellers to be up-to-date with screening guidelines (multivariate odds ratio, 0.65; 95% confidence interval, 0.53-0.79). In the unadjusted analysis, rural vs urban residence (P < .001), travel time to the nearest colonoscopy provider (P = .003), and spatial accessibility of providers (P = .012) were associated significantly with adherence to screening guidelines. However, rural vs urban residence (P < .001) was the only geographic variable independently associated with screening adherence in the adjusted analyses. There are marked disparities in use of risk-appropriate CRC screening between rural and urban residents in Utah. Differences in travel time to the nearest colonoscopy provider and spatial accessibility of providers did not account for the geographic variations observed in screening adherence.

Disparities in use of gynecologic oncologists for women with ovarian cancer in the United States.

To examine disparities in utilization of gynecologic oncologists (GOs) across race and other sociodemographic factors for women with ovarian cancer. Obtained SEER-Medicare linked dataset for 4,233 non-Hispanic White, non-Hispanic African American, Hispanic of any race, and Non-Hispanic Asian women aged ≥ 66 years old diagnosed with ovarian cancer during 2000-2002 from 17 SEER registries. Physician specialty was identified by linking data to the AMA master file using Unique Physician Identification Numbers. Retrospective claims data analysis for 1999-2006. Logistic regression models were used to analyze the association between GO utilization and race/ethnicity in the initial, continuing, and final phases of care. GO use decreased from the initial to final phase of care (51.4-28.8 percent). No racial/ethnic differences were found overall and by phase of cancer care. Women >70 years old and those with unstaged disease were less likely to receive GO care compared to their counterparts. GO use was lower in some SEER registries compared to the Atlanta registry. GO use for the initial ovarian cancer treatment or for longer term care was low but not different across racial/ethnic groups. Future research should identify factors that affect GO utilization and understand why use of these specialists remains low.

Gender Differences in Questions Asked in an Online Preoperative Patient Education Program

Although osteoarthritis more commonly affects women than men, women are 3 times less likely to undergo hip or knee replacement surgery compared with men. Disparity in the appropriate utilization of surgery between men and women is a complex subject that must take into account the willingness of a patient to proceed with the operation. Adequately addressing patient concerns before surgery may influence such willingness. We examined if a gender difference can be identified in the frequency and types of questions submitted by patients scheduled for total hip or total knee arthroplasty. Patients completed an online interactive preoperative educational program and a database was created containing deidentified information on surgical procedure, sex, year of birth, and any questions that were submitted. Data were also available regarding the total number of patients issued the program, the number of patients who started the program, and the number of patients who completed the program. The results were analyzed by Wilcoxon rank sum test. P values ≤0.05 were considered statistically significant. Among the 2770 women and 1708 men included in the study, 935 (34%) and 462 (27%) asked at least 1 question, respectively. Compared with men, women asked a significantly greater number of questions overall (P < 0.001). Women also asked a significantly greater number of questions in the categories Your Condition (P = 0.031), Your Procedure (P < 0.001), and Risks and Benefits (P < 0.001). Gender differences in concerns and physicians' ability to adequately address these concerns may contribute to disparity in use of hip and knee replacement surgery between men and women. Effective preoperative counseling for women may require additional resources to address their higher level of questions.

Variations in Children’s Dental Service Use Based on Four National Health Surveys

To compare estimates of dental service use and delayed dental care across 4 national surveys of children's health. Among children 2 to 17 years of age, prevalence estimates of the use of any dental services, preventive dental services, and delayed dental care in the past year were obtained from the 2003 and 2007 National Survey of Children's Health, the 2003-2004 National Health and Nutrition Examination Survey (NHANES), the 2003 and 2007 National Health Interview Survey, and the 2003 and 2007 Medical Expenditure Panel Survey. Trends in parent-reported dental use, including delayed care, by sociodemographic characteristics were assessed by using logistic regression and odds ratios. Data collection methodologies varied across the 4 surveys, and estimates of dental service use varied accordingly. Surveys differed in the survey items used, recall time frames, and protocols for eliciting visit history. As a result, estimates of any dental use ranged from 52% to 81%, whereas estimates of preventive dental use ranged from 67% to 78%. Rates of delayed dental care were low, ranging from 3% to 8%; however, surveys showed consistent sociodemographic disparities in use of dental services and delayed dental care. Each survey has a unique approach to defining and eliciting parents' reports of children's dental service use, which could result in under- or overestimation of the number and nature of children's dental services. Each survey's methodology must be considered when accepting population-based estimates of dental service use to monitor progress in achieving national oral health goals.

Ethnic disparities in colonoscopy use among colorectal cancer survivors: a systematic review.

After curative treatment for colorectal cancer (CRC), routine colonoscopies are recommended. We aimed to identify all studies of ethnic disparities in CRC surveillance and examine any association between race/ethnicity and colonoscopy use. We conducted a systematic literature review to address the association between race/ethnicity and colonoscopy use among CRC survivors. We searched Medline for relevant articles. Two authors reviewed titles, abstracts, and articles based on pre-determined inclusion/exclusion criteria. Of the 1,544 titles reviewed, eight studies published since 2001 investigated racial/ethnic disparities in colonoscopy use. Four articles showed a small significant ethnic disparity in the receipt of timely colonoscopy, and the remaining four articles showed a nonsignificant trend in the same direction. The effect did not vary by time of diagnosis or proportion of minorities in each study, though studies with larger samples showed somewhat greater racial/ethnic disparities in colonoscopy use. We found at least a small disparity in the use of colonoscopy among CRC survivors, suggesting that ethnic disparities continue beyond prevention, detection, and treatment of CRC. It is important to identify areas of unequal care in CRC survivorship and to promote timely surveillance among CRC survivors who belong to racial/ethnic minorities to decrease disparities in mortality. CRC survivors who belong to racial/ethnic minorities may be less likely to receive follow-up colonoscopies on time, which could contribue to higher rates of death from CRC among minorities.

Socioeconomic Disparities in Ophthalmology Services among Diabetic Patients in Alberta

Screening for diabetic retinopathy (DR) is recommended by the Canadian Diabetes Association (CDA) Clinical Guidelines in order to detect disease timely and prevent blindness. Despite this recommendation, the rate of DR screening services in diabetic patients in Alberta has decreased over the past years. The aim of this study was to examine socioeconomic status (SES)-related disparities in the use of ophthalmologists’ services for diabetic patients in Alberta. This study used data from the Alberta Diabetes Surveillance System (ADSS), including visits to ophthalmologists between 1996 - 2009. The entire diabetic population in Alberta(86,935 in 1996, 121,014 in 2001, 170,888 in 2006 and 205,726 in 2009) was included in the analysis. SES disparities in ophthalmologist visits were assessed using the Concentration Index (CI), which ranges from -1 to +1. Pampalon's material and social deprivation indices, at Alberta's sub-region level, were used as SES measures. We found that disparities in use of ophthalmology services exist in diabetic patients, although the magnitudes of the disparities have steadily decreased over time. More socially deprived groups are more likely to use ophthalmology services compared to less socially deprived groups (CI- 1996:+0.070; 2001:+0.050; 2006:+0.045; 2009:+0.043). On the other hand, less materially deprived groups are more likely to receive ophthalmologist services (CI-1996:-0.073; 2001:-0.048; 2006:-0.035; 2009:-0.029). Further stratification by age, sex, geography and First Nation status needs to be considered. Our findings suggest the need to develop a policy to reduce both social and material deprivation-related disparities in the provision of ophthalmology services in diabetic patients.

Do Racial and Ethnic Differences in Contraceptive Attitudes and Knowledge Explain Disparities In Method Use?

Sustained efforts have not attenuated racial and ethnic disparities in unintended pregnancy and effective contraceptive use in the United States. The roles of attitudes toward contraception, pregnancy and fertility remain relatively unexplored. Knowledge of contraceptive methods and attitudes about contraception, pregnancy, childbearing and fertility were assessed among 602 unmarried women aged 18-29 at risk for unintended pregnancy who participated in the 2009 National Survey of Reproductive and Contraceptive Knowledge. The contribution of attitudes to racial and ethnic disparities in effective method use was assessed via mediation analysis, using a series of regression models. Blacks and Latinas were more likely than whites to believe that the government encourages contraceptive use to limit minority populations (odds ratio, 2.5 for each). Compared with white women, Latinas held more favorable attitudes toward pregnancy (2.5) and childbearing (coefficient, 0.3) and were more fatalistic about the timing of pregnancy (odds ratio, 2.3); blacks were more fatalistic about life in general (2.0). Only one attitude, skepticism that the government ensures contraceptive safety, was associated with contraceptive use (0.7), but this belief did not differ by race or ethnicity. Although blacks and Latinas used less effective methods than whites (0.3 and 0.4, respectively), attitudes did not explain disparities. Lower contraceptive knowledge partially explained Latinas' use of less effective methods. Providing basic information about effective methods might help to decrease ethnic disparities in use. Research should examine other variables that might account for these disparities, including health system characteristics and provider behavior.

Rural–urban disparities in use of post-lumpectomy radiation

We hypothesized that breast cancer (BCa) patients in urban counties would have higher rates of post-lumpectomy radiation therapy (RT) relative to patients in near-metro and rural counties. We used the Surveillance, Epidemiology, and End Results (SEER) database to identify women diagnosed with BCa treated with lumpectomy in the Sacramento area between 2000 and 2006. Patient counties were categorized as urban and near-metro. Multivariate logistic regression models predicted treatment with RT. Likelihood of undergoing RT was reported as odds ratios (OR) with 95 % confidence intervals (CI). Of 7,953 patients meeting entry criteria, 5,858 (73.7 %) underwent RT. On multivariate analysis, patients from near-metro (OR, 0.66; CI, 0.59-0.75; P < 0.001) and rural (OR 0.39, CI 0.30-0.52; P < 0.001) areas had a decreased likelihood of undergoing RT relative to patients from urban areas. Patients from near-metro and rural areas are less likely to receive RT following lumpectomy for BCa than their urban counterparts.

Changes in Racial-Ethnic Disparities in Use and Adequacy of Mental Health Care in the United States, 1990–2003

This study examined changes in white-black and white-Latino disparities in the use of any mental health care and minimally adequate mental health care. Using data from the 1990&#x02013;1992 National Comorbidity Survey (NCS) and the 2001&#x02013;2003 National Comorbidity Survey Replication (NCS-R), this study examined changes by race-ethnicity in use of mental health care among individuals age 18 to 54 with a 12-month mood or anxiety disorder. The sample consisted of 1,198 NCS respondents and 929 NCS-R respondents. Changes in disparities were estimated in the use of any mental health care in the general medical sector, the specialty mental health sector, and in total. Changes in disparities were also estimated in the use of minimally adequate mental health care (in total only). Disparities in the use of any mental health care increased over time, particularly between non-Latino whites and non-Latino blacks in the general medical sector and between non-Latino whites and Latinos in the specialty mental health sector. Disparities in the use of minimally adequate mental health care persisted between whites and blacks over time but were not detected between whites and Latinos in either period. The findings of greater racial-ethnic disparities in the general medical and specialty mental health sectors indicate that more targeted policies and programs are needed to increase use of mental health care in these health sectors among persons from racial-ethnic minority groups. The persistence of white-black disparities in the use of minimally adequate mental health care warrants further examination.

Sociodemographic and patient disparities in use of first-line chemotherapy (CT) in older adult patients (pts) with advanced non-small cell lung cancer (AdvNSCLC): Analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare data.

6131 Background: Clinical trials have demonstrated that CT improves survival and quality of life in pts with AdvNSCLC. Our prior studies suggest that only 26% of older pts diagnosed with AdvNSCLC received CT through 2002. In this study, we examined more recent patterns, and the effect of socio-demographics, race, and age on receipt of CT in older pts with AdvNSCLC. Methods: Medicare pts diagnosed with AdvNSCLC from 2001-2005 were identified in SEER registries. Medicare enrollment data provided demographic information (age, race, sex, marital status), augmented with census tract level data on median household income. Comorbid conditions at baseline were identified by ICD9-CM diagnoses on claims. Receipt of 1st line CT was identified based on agent-specific procedure codes in claims. Logistic regression examined predictors of 1st line CT. Results: Of 31,341 pts with Adv NSCLC, 34% received 1st line CT. As reflected in the table, poor predicted PS (PredPS), multiple medical comorbidities, and black race were associated with lower likelihood of CT receipt. Being female, married, having higher income, and being diagnosed at a later year were associated with a higher likelihood of receiving CT. Conclusions: Even when controlling for factors such as PS, our results suggest the presence of age, race, and socio-economic disparities in the receipt of 1st line CT for older patients with AdvNSCLC. [Table: see text]

Abstract 136: Impact of Massachusetts Health Reform on Racial and Ethnic Disparities in Use of Inpatient Cardiovascular Surgeries

BACKGROUND The 2006 Massachusetts (MA) health reform increased insurance coverage to near-universal levels, but its impact on access to care or disparities in access is unclear. We examined post-reform change in racial/ethnic differences in use of two cardiovascular (CV) procedures, percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG), for which disparities in use have been noted in numerous past studies. As use of these procedures is sensitive to outpatient referral, impact of reform on procedure use can serve as a marker for impact on access to care. We hypothesized that reform will result in increased use of procedures, and that the increase in use will be greater among minorities. We contrasted the results with those for two comparable orthopedic procedures (total knee replacement [TKR] and total hip replacement [THR]). METHODS Using the comprehensive MA Hospital Inpatient Data of all discharges in all non-Federal hospitals from 1/1/2004 to 9/30/2009, we obtained state-level counts of individual procedures stratified into 30 cohorts by age (40-44, 45-49, 50-54, 55-59 &amp; 60-64), sex and race/ethnicity (Whites, Blacks and Hispanics) for each quarter. To separate the impact of MA reform from secular changes, we used corresponding data from New York (SPARCS Inpatient Data) to capture changes unrelated to MA reform. To convert procedure counts into rates (# procedures/10,000 population), we obtained Census data to create a measure of population at risk for each cohort. Treating a quarter as the unit of time, the study period comprised of 10 pre-reform, 6 transition and 7 post-reform quarters. Applying a difference-in-difference specification, we used segmented time series Poisson regression models to estimate the impact of MA reform on the procedure rates for Blacks and Hispanics relative to those for Whites. RESULTS There was a secular decrease in MA in the use of PTCA and CABG (-8.0% per year for each) throughout the study period. In MA, compared to Whites, pre-reform rates of both procedures were lower among Blacks (Incidence Rate Ratio [IRR]: PTCA=0.79 &amp; CABG=0.73; all p values &lt; 0.001) but similar among Hispanics. For the post-reform period, the procedure rate in MA was unchanged for PTCA but was 11% higher (95%CI=[2%, 20%]) for CABG. MA reform was associated with 11% higher post-reform rates of PTCA+CABG (combined) use among Hispanics, albeit with marginal significance (95% CI=[-1%, 25%]), than that among Whites; no significant impact was noted for Blacks (2%; 95% CI=[-10%, 16%]). Orthopedic procedures experienced secular increases in use. Reform was associated with increased use of both procedures among Blacks (16%, 95% CI=[3%, 31%]) and Hispanics (42%, 95% CI=[20%, 69%]) than that among Whites. CONCLUSIONS MA health reform may have increased the use of CV and orthopedic procedures among minorities. While orthopedic procedure use increased among both Blacks and Hispanics, the increase for CV procedures was smaller in magnitude and limited to Hispanics. Impact of reform on use may vary with procedure type due to differences in pent-up demand and acuity of conditions treated.

Human Papillomavirus Vaccine Use Among Adolescent Girls and Young Adult Women: An Analysis of the 2007 California Health Interview Survey

Administration of the human papillomavirus (HPV) vaccine is recommended for adolescent girls and young adult women. Little is known about the factors associated with vaccination. This study examined prevalence and correlates of HPV vaccine initiation (≥1 dose) among a statewide representative sample of adolescent and young adult females living in California. HPV vaccination data on 3615 parents of adolescent girls aged 12-17 and 2068 young adult women aged 18-27 from the 2007 California Health Interview Survey (CHIS) were examined by sociodemographic, healthcare access, and health behavior factors using chi-square and multivariable logistic regression models. Nineteen percent of adolescent girls and 11% of young adult women had initiated the HPV vaccine series. In both groups, lower educational attainment (parental/own) was associated with lack of vaccine initiation. For adolescents, vaccine initiation was also significantly lower among those whose parents had low incomes or no usual source of care. For young adults, initiation was lower among the older group and those who spent less time in the United States, had public insurance, had no recent provider visit, or had fewer sexual partners. In a statewide representative sample, different correlates of early initiation of HPV vaccination emerged for Californian adolescent girls and young adult women. These different patterns may be due to differential access to programs that provide free or low-cost HPV vaccines. Because several of these factors are associated with disparities in use of Pap tests, disparities will persist or even worsen unless greater effort is placed on vaccinating populations at highest risk for cervical cancer.

Trends in use of implantable cardioverter-defibrillator therapy among patients hospitalized for heart failure: have the previously observed sex and racial disparities changed over time?

Prior studies have demonstrated low use of implantable cardioverter defibrillators (ICDs) as primary prevention, particularly among women and blacks. The degree to which the overall use of ICD therapy and disparities in use have changed is unclear. We examined 11 880 unique patients with a history of heart failure and left ventricular ejection fraction ≤35% who were ≥65 years old and enrolled in the Get With the Guidelines-Heart Failure (GWTG-HF) program from January 2005 through December 2009. We determined the rate of ICD use by year for the overall population and for sex and race groups. From 2005 to 2007, overall ICD use increased from 30.2% to 42.4% and then remained unchanged in 2008 to 2009. After adjustment for potential confounders, ICD use increased significantly in the overall study population during 2005 to 2007 (odds ratio, 1.28; 95% confidence interval, 1.11-1.48 per year; P=0.0008) and in black women (odds ratio, 1.82; 95% confidence interval, 1.28-2.58 per year; P=0.0008), white women (odds ratio, 1.30; 95% confidence interval, 1.06-1.59 per year; P=0.010), black men (odds ratio, 1.54; 95% confidence interval, 1.19-1.99 per year; P=0.0009), and white men (odds ratio, 1.25; 95% confidence interval, 1.06-1.48 per year; P=0.0072). The increase in ICD use was greatest among blacks. In the GWTG-HF quality improvement program, a significant increase in ICD therapy use was observed over time in all sex and race groups. The previously described racial disparities in ICD use were no longer present by the end of the study period; however, sex differences persisted.

Disparities in Cardiac Care for Patients With Complex Cardiovascular Care Needs

The United States continues to have a prevailing public health problem related to disparities in healthcare. Factors contributing to disparities include ethnicity, gender, socioeconomic status, educational level, geographic location, and hospital characteristics. In cardiovascular care, gaps in care have been associated with lack of conformity to evidence-based therapies known to improve clinical outcomes, including survival, quality of life, and freedom from rehospitalization. Specifically, there are disparities in use of a number of cardiovascular life-saving procedures including cardiac catheterization, percutaneous coronary intervention, coronary artery bypass surgery, and implantation of defibrillators and cardiac resynchronization devices. The purpose of this article was to illustrate the range of disparities that exist in relation to management of patients with acute coronary syndromes, interventional cardiology procedures, cardiac surgery, heart failure, and device implantation. Because the impact on patient outcomes is high, potential interventions to address disparities will be provided.

Educational level and use of osteoporosis drugs in elderly men and women: a Swedish nationwide register-based study

We examined educational disparities in use of osteoporosis drugs in a nationwide population of Swedes aged 75-89 years old. Individuals with high education were more likely to receive osteoporosis drug treatment than lower educated individuals, particularly among women. This study aims to investigate whether educational level is associated with use of osteoporosis drugs in the general population of older men and women in Sweden, also after adjustment for fractures. By record linkage of The Swedish Prescribed Drug Register, The Swedish Patient Register, and The Swedish Education Register, we obtained information on filling of prescriptions for osteoporosis drugs (bisphosphonates, calcium/vitamin D combinations, and selective estrogen receptor modulators) from July to October 2005, osteoporotic fractures from 1998 to 2004, and educational level for 645,429 people aged 75-89 years. Multivariate logistic regression analysis was used to investigate whether education was associated with use of osteoporosis drug therapy. Higher education was associated with use of osteoporosis drugs for both men [odds ratio (OR)(high education vs low), 1.27; 95% confidence interval (CI), 1.19-1.35] and women (OR(high education vs low), 1.57; 95% CI, 1.52-1.61), after adjustment for age, osteoporotic fractures, and comorbidity (i.e., number of other drugs). Among those who had sustained a fracture (n = 57,613), the educational differences in osteoporosis drug treatment were more pronounced in women than men. Further, women were more likely to receive osteoporosis drug treatment after osteoporotic fracture. Uptake of osteoporosis drug therapy seems to be unequally distributed in the elderly population, even in a country with presumably equal access to health care.

Race and sexual behavior predict uptake of the human papillomavirus vaccine.

To identify predictors of human papillomavirus (HPV) vaccination initiation by girls at high risk for HPV infection. Participants were 2,098 girls enrolled in the ongoing Pittsburgh Girls Study, who were between the ages of 12 and 15 years in 2008, and their primary caregivers. The study was conducted in the 2 years after the deployment of the first HPV vaccine approved by the U.S. Food and Drug Administration. Primary caregivers were asked about HPV vaccine uptake. Girls were interviewed about pubertal development and sexually intimate behavior. Approximately 60% of the girls had initiated the HPV vaccine in the past year. Among the hypothesized predictors of initiation, African-American race decreased the likelihood and level of sexually intimate behavior in the previous year increased the likelihood of uptake. Controlling for receipt of public assistance, African-American girls were close to 40% less likely to be vaccinated than European-American girls. Racial disparities in use of preventive interventions such as the HPV vaccine exist. Lack of information about public financing of the vaccine, timing of vaccination relative to sexual activity, and perceptions of preventive value may limit uptake among those at highest risk for infection and negative sequelae from infection. Further research to probe knowledge and attitudes toward HPV vaccination and the impact of the media on vaccine initiation and uptake may reveal specific targets of intervention.

Decomposing Racial and Ethnic Disparities in the Use of Postacute Rehabilitation Care

To determine the degree to which racial and ethnic disparities in the use of postacute rehabilitation care (PARC) are explained by observed characteristics. State inpatient databases (SIDs) for 2005 and 2006 from four diverse states were used to identify patients with stays for joint replacement, stroke, or hip fracture. Our primary outcomes were use of institutional PARC (versus discharge home) and, conditional on discharge to an institution, skilled nursing facility (versus inpatient rehabilitation facility) care. We modified the Oaxaca-Blinder decomposition method to account for the dichotomous outcome and multilevel nature of the data. Discharges from the four SIDs were included if the principal diagnosis (stroke, hip fracture) or procedure (joint replacement) was in the sample inclusion criteria. Observed characteristics explained roughly half of the unadjusted differences in use of institutional PARC. Patient-level factors (clinical, age) were more explanatory of disparities in institutional PARC use, while hospital-level factors were more explanatory of skilled nursing facility versus inpatient rehabilitation facility care. Adjustment for characteristics influencing PARC use both mitigated and exacerbated racial/ethnic disparities in use. The degree to which the characteristics explained the disparity varied across conditions and outcomes.

Disappearing and reappearing differences in drug-eluting stent use by race.

Drug-eluting coronary stents (DES) rapidly dominated the marketplace in the United States after approval in 2003, but utilization rates were initially lower among African American patients. We assess whether racial differences persisted as DES diffused into practice. Medicare claims data were used to identify coronary stenting procedures among elderly patients with acute coronary syndromes (ACS). Regression models of the choice of DES versus bare mental stent controlled for demographics, ACS type, co-morbidities and hospital characteristics. Diffusion was assessed in the short run (2003-2004) and long run (2007), with the effect of race calculated to allow for time-varying effects. The sample included 381,887 Medicare beneficiaries treated with stent insertion; approximately 5% were African American. Initially (May 2003-February 2004), African American race was associated with lower DES use compared to other races (44.3% versus 46.5%, P < 0.01). Once DES usage was high in all patients (March-December 2004), differences were not significant (79.8% versus 80.3%, P = 0.45). Subsequent concerns regarding DES safety caused reductions in DES use, with African Americans having lower use than other racial groups in 2007 (63.1% versus 65.2%, P < 0.01). Racial disparities in DES use initially disappeared during a period of rapid diffusion and high usage rates; the reappearance of disparities in use by 2007 may reflect DES use tailored to unmeasured aspects of case mix and socio-economic status. Further work is needed to understand whether underlying differences in race reflect decisions regarding treatment appropriateness.

Differences in national antiretroviral prescribing patterns between black and white patients with HIV/AIDS, 1996-2006.

The benefit of improved health outcomes for blacks receiving highly active antiretroviral therapy (HAART) lags behind that of whites. This project therefore sought to determine whether the reason for this discrepancy in health outcomes could be attributed to disparities in use of antiretroviral therapy between black and white patients with HIV. The 1996-2006 National Hospital Ambulatory Medical Care Surveys were used to identify hospital outpatient visits that documented antiretrovirals. Patients younger than 18 years, of nonblack or nonwhite race, and lacking documentation of antiretrovirals were excluded. A multivariable logistic regression model was constructed with race as the independent variable and use of HAART as the dependent variable. Approximately 3 million HIV/AIDS patient visits were evaluated. Blacks were less likely than whites to use HAART and protease inhibitors (odds ratio, 95% CI 0.81 [0.81-0.82] and 0.67 [0.67-0.68], respectively). More blacks than whites used non-nucleoside reverse transcriptase inhibitors (odds ratio, 95% CI 1.18 [1.17-1.18]). In 1996, the crude rates of HAART were relatively low for both black and white cohorts (5% vs 6%). The rise in HAART for blacks appeared to lag behind that of whites for several years, until 2002, when the proportion of blacks receiving HAART slightly exceeded the proportion of whites receiving HAART. In later years, the rates of HAART were similar for blacks and whites (81% vs 82% in 2006). Blacks appeared less likely than whites to use protease inhibitors and more likely than whites to use non-nucleoside reverse transcriptase inhibitors from 2000 to 2004. Blacks experienced a lag in the use of antiretrovirals at the beginning of the study; this discrepancy dissipated in more recent years.

Abstract P98: Change in Racial and Ethnic Disparities in Use of Inpatient Cardiovascular Surgeries in Postreform Massachusetts

BACKGROUND The 2006 Massachusetts (MA) health reform increased insurance coverage to near-universal levels, but its impact on access to care is not known. We examined post-reform change in racial/ethnic differences in use of two cardiovascular procedures - percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) - and two non-cardiovascular procedures (knee and hip replacements) documented to be underutilized by minorities. METHODS Using discharge data on all MA hospitalizations for 21 months preceding and following implementation of the reform, we identified all PTCA, CABG and joint (knee, hip) replacement procedures performed for patients aged &gt;=40. Stratifying census population by race/ethnicity, we estimated pre- and post-reform population-based procedure rates, and their changes, for those aged 40-64, adjusting for secular changes unrelated to reform by capturing corresponding changes for those aged &gt;= 65, whose coverage (Medicare) was unaffected by reform. RESULTS There was a secular decrease in use of PTCA and CABG for all groups (of 18% or more); use of joint replacement increased (&gt;=20%). Post-reform, Black/White ratio of combined PTCA &amp; CABG procedure rate improved from 0.77 to 0.82, with a smaller decrease for Blacks (18%) than Whites (24%). Difference in Hispanic/White PTCA &amp; CABG procedure rate was not significant pre- and post-reform. Post-reform change associated with reform was not significant. Use of joint replacement increased for both minorities vs. Whites; change associated with reform was sizable for all groups (&gt;=7%; significant for Whites only). CONCLUSIONS Use of inpatient PTCA and CABG shows a largely secular decrease, with little change associated with reform. While Black-White difference in PTCA and CABG rate decreased marginally, the rate among Blacks remained significantly lower than for Whites and Hispanics. Limitation: clinical appropriateness of the procedures could not be confirmed. Table 1. Differences in Procedure Rates and Post-Reform Change in Massachusetts: Age 40-64 PTCA &amp; CABG Knee &amp; Hip Replacement Whites Blacks Hispanics Whites Blacks Hispanics Pre-reform Procedure Rate/10,000 pop. c 38 29 38 30 31 13 Procedure Rate Ratio, Non-White/White (p-value for test of ratio=1) 0.77*** 0.99 1.03 0.42*** Post-reform Procedure Rate/10,000 pop. c 29 24 31 35 41 18 Procedure Rate Ratio, Non-White/White (p-value for test of ratio=1) 0.82*** 1.04 1.18** 0.52*** Total Post-reform Change, % d -24%*** -18%*** -19%*** 20%*** 36%*** 40%*** Difference, Non-White -White (p-value for test of difference=0) 5.2% 5.1% 16%* 20%** Net Post-reform Change, % e (p-value for test of change=0) -0.9% -2.2% 2.9% 7%*** 12% 18% a) ***, ** and * denote p-value &lt;=0.001, &lt;=0.01 and &lt;=0.05 respectively b) Pre-reform period=(Oct 2004 to Jun 2006) and post-reform period=(Jan 2008 to Sept 2009) are 21 months each c) Procedure rates, adjusted for sex and age differences, are estimated by direct standardization method d) Total post-reform change in procedure rate is the simple % change in the pre-and post-reform procedure rates. e) Net post-reform change is the estimate of change in procedure rate associated with the health reform. To separate the impact of health reform from secular temporal effects that may be unrelated to health reform, we used a difference-in-difference specification of a hierarchical Poisson regression model to estimate the net change among the 40-64 age group by contrasting the corresponding change for those among patients aged ≥65, assuming they had continuous Medicare coverage that was unaffected by the reform