White Beneficiaries Research Articles

EXPRESS: Racial Inequity in Donation-based Crowdfunding Platforms: the Role of Facial Emotional Expressiveness

Donation-based crowdfunding platforms often claim to pursue equitable outcomes for all beneficiaries, yet many face criticism for failing to do so across different demographic profiles. In response, platform managers are eager to understand how these inequities emerge and explore solutions to address them. In this research, we show that the degree of facial emotional expressiveness of beneficiaries in uploaded images can differentially impact donation amounts for White vs Black beneficiaries. Drawing on social vision theory, we propose that facial emotional expressiveness in images combined with the race of the faces activates racial stereotypes of emotion expression that result in differential donation amounts to Black and White individuals. Analyzing a sample of 4,153 campaigns from GoFundMe between June 2021 and September 2022, along with a follow-up experiment, we find that higher facial emotional expressiveness is associated with significantly lower donation amounts for Black compared to White beneficiaries. Further exploring our moderating constructs reveals that the use of call-to-action cues, affective messaging, and race-gender homophily cues can attenuate the activation of stereotypes and therefore reduce differences in donation amounts between racial groups. Based on these findings, we offer targeted recommendations for platform managers to help reduce racial inequities in crowdfunding outcomes.

Risk for Financial Precarity From Hospitalization: Implications for Targeting Financial Assistance in Medicare.

High out-of-pocket costs in Medicare may leave many beneficiaries in financial precarity. Beneficiaries with modest incomes are often ineligible for Medicaid (which covers most out-of-pocket Medicare costs) and may have insufficient resources to pay an unexpected health care bill. This has prompted calls to improve financial protections, but the target population remains uncharacterized. To identify beneficiaries who would face financial precarity if exposed to the Medicare Part A hospital deductible ($1600). Cross-sectional study of the 2018 wave of the Health and Retirement Study. United States. Community-dwelling Medicare beneficiaries with incomes greater than 100% to 400% or less of the federal poverty level. Nationally representative estimates of financial precarity, defined as having insufficient funds to pay the deductible, examined across 4 scenarios that considered checking and savings account balances, total liquid assets (with a reserve for future living costs), and supplemental insurance. Among 4881 beneficiaries (population weighted n = 26 619 823), 45.0% had insufficient funds in checking and savings accounts to pay the Medicare hospital deductible. Financial precarity was more prevalent among Black and Hispanic versus White beneficiaries (73.5% and 76.2% vs. 36.2%), those with less versus more than high school education (70.0% vs. 37.1%), and those with 3 or more versus 2 or fewer chronic conditions (49.2% vs. 39.1%). In defining financial precarity to include beneficiaries with insufficient liquid assets to pay the deductible while maintaining a $5000 reserve for future living expenses, 50.7% were financially precarious. Building off this definition to assume supplemental insurance covered the deductible, 39.0% remained financially precarious. Cost-sharing exposure is limited to hospitalization. Many Medicare beneficiaries with modest incomes are at risk for financial hardship from costs of a single hospital stay. National Institute on Aging.

Racial/ethnic disparities in cost-related barriers to care among near-poor beneficiaries in Medicare Advantage vs traditional Medicare.

To compare racial and ethnic disparities in cost-related medical care and dental care barriers and use of vision care among near-poor Medicare beneficiaries in Medicare Advantage (MA) vs traditional Medicare (TM) overall and stratified by supplemental insurance enrollment. Cross-sectional analysis of 2015-2019 data from the nationally representative Medicare Current Beneficiary Survey. Propensity score-weighted difference-in-disparities analyses comparing Black-White and Hispanic-White disparities in MA vs TM among near-poor Medicare beneficiaries with incomes between 101% and 250% of the federal poverty level. We assessed differences in cost-related medical care barriers and cost-related dental care barriers as well as receipt of annual eye exams in MA vs TM. For cost-related barriers to medical care, Hispanic-White disparities were narrower by 8.8 (95% CI, -14.0 to -3.6) percentage points in MA relative to TM but differences in Black-White disparities were not statistically significant. MA was not associated with narrower differences in Hispanic-White or Black-White disparities in dental care access. Higher proportions of Black and Hispanic beneficiaries in MA received an annual eye exam vs White beneficiaries in both MA and TM. MA was associated with narrower racial disparities primarily compared with TM without supplemental insurance. Among near-poor Black and Hispanic Medicare beneficiaries, MA was associated with greater use of vision care and narrowing of some disparities in cost-related access barriers vs TM. However, MA did not uniformly narrow racial/ethnic disparities in access and use. These findings highlight the importance of maintaining and enhancing features of Medicare coverage that may promote equitable access to care, including additional benefits and lower cost sharing.

Racial Disparities in Outpatient Physical Therapy Use After Hip Fracture: A Retrospective Cohort Study

INTRODUCTION: The objective of our study was to examine whether there is a racial disparity among Medicare beneficiaries in the likelihood of using outpatient PT services following a hip fracture. METHODS: Our retrospective descriptive cohort study analyzed administrative claims data for 51,781 Medicare beneficiaries post-hip fracture. We examined the association between race and physical therapy (PT) use within the first 6 months post-fracture using hierarchical logistic regression, adjusting for demographics, medical complexity, and socioeconomic factors. We used Poisson regression to examine the association between race and the number of PT visits. RESULTS: Only 31% of beneficiaries used outpatient PT after hip fracture with significant racial disparities. After controlling for demographics, medical complexity, and socioeconomic factors, Black beneficiaries had 42% lower odds of using PT [aOR = 0.58, 95% CI 0.51-0.66] compared to White beneficiaries. Among PT users, Black beneficiaries received fewer visits than White beneficiaries (RR = 0.85, 95% CI 0.82-0.88) with this disparity persisting after adjustments (RR = 0.88, 95% CI 0.85-0.91). CONCLUSION: Even after adjusting for demographic, medical, and socioeconomic factors, Black beneficiaries were less likely to use outpatient PT following hip fractures. Conditional on an initial PT evaluation, Black beneficiaries received fewer sessions.

Incident Epilepsy Among US Medicare Beneficiaries, 2019: Differences by Age, Sex, and Race/Ethnicity.

Epilepsy is common among older adults, but previous incident studies have had limited ability to make comparisons across key subgroups. We aimed to provide updated epilepsy incidence estimates among older adults, comparing across age, sex, and race/ethnicity. Using a random sample of 4,999,999 US Medicare beneficiaries older than 65 years, we conducted a retrospective cohort study of epilepsy incidence using administrative claims for 2016-2019. Sampled beneficiaries were enrolled in the Fee-for-Service (FFS) program in each of 2016-2018 and had no epilepsy claims in those years. Non-Hispanic Black and Hispanic beneficiaries were oversampled to ensure adequate cases for detailed comparisons. Incidence in 2019 was identified in the Master Beneficiary Summary File as ≥1 inpatient claim or ≥2 outpatient nondrug claims occurring at least 1 day apart (ICD-10 G40.x). Incidence models were estimated by age, sex, race/ethnicity, and combinations thereof, with adjustment for the racial/ethnic oversampling. We identified 20,545 incident epilepsy cases. The overall epilepsy incidence rate (IR) was 393 per 100,000 (99% CI 385-400). Incidence peaked at ages 85-89 (504 [481-529]) and was higher for men (396 [385-407]) than women (376 [366-385]). The sex difference in IRs was constant with age. Incidence was higher for non-Hispanic Black (678 [653-702]) and Hispanic (405 [384-426]), and lower for non-Hispanic Asian/Pacific Islander (272 [239-305]) beneficiaries, compared with non-Hispanic White beneficiaries (354 [299-408]). The age-specific IRs significantly differed by race/ethnicity and sex, but only among non-Hispanic Black beneficiaries-where men had higher rates at younger ages and women at older ages. We found higher epilepsy IRs among those enrolled in the Medicare FFS system 2016-2019 than previous studies using Medicare claims data from at least a decade ago. The risk of epilepsy onset is higher for those in their late 80s, men, and non-Hispanic Black and Hispanic older adults. There is also evidence that these age-graded risks operate differently for Black men and Black women. Efforts to provide care and services that improve quality of life for older adults living with epilepsy should consider differences by multiple social characteristics simultaneously: age, sex, and race/ethnicity.

Differences in opioid prescriptions by race among U.S. older adults with a hip fracture transitioning to community care.

Appropriate pain management can facilitate rehabilitation after a hip fracture as patients transition back to the community setting. Differences in opioid prescribing by race may exist during this critical transition period. We conducted a retrospective cohort study of older adult U.S. Medicare beneficiaries with a hip fracture to examine whether the receipt and dose of opioids differs between Black and White patients as they transitioned back to the community setting. We stratified beneficiaries by whether they received institutional post-acute care (PAC). Outcomes were (1) receipt of an opioid and (2) opioid doses in the first 90 days in the community in milligram morphine equivalents (MMEs; also presented in mg oxycodone). We estimated relative rates and risk differences of opioid receipt and dose differences using Poisson and linear regression models, respectively, using the parametric g-formula to standardize for age and sex. We identified 164,170 older adults with hip fracture (mean age = 82.7 years; 75% female; 72% with PAC; 46% with opioid use after fracture). Overall use of opioids in the community was similar between Black and white beneficiaries. Black beneficiaries had lower average doses in their first 90 days in both total cumulative doses (PAC group: 165 [95% CI -264 to -69] fewer MMEs [-248 mg oxycodone]; no PAC: 167 [95% CI -274 to -62] fewer MMEs [-251 mg oxycodone]) and average MME per days' supply of medication (PAC: -3.0 [-4.6 to -1.4] fewer MMEs per day [-4.5 mg oxycodone]; no PAC: -4.7 [-4.6 to -1.4] fewer MMEs per day [-7.1 mg oxycodone]). In secondary analyses, Asian beneficiaries experienced the greatest differences (e.g., 617-653 fewer cumulative mg oxycodone). Racial differences exist in pain management for Medicare beneficiaries after a hip fracture. Future work should examine whether these differences result in disparities in short- and long-term health outcomes.

Racial and Ethnic Underserved Populations Prescription Analgesic Use Before and After Lower Extremity Amputation in US Medicare.

Racial disparities exist in access to health care and management of multiple health conditions including chronic pain; however, racial disparities in pre- and postoperative pain management in lower extremity amputation are not well-studied. Our objective was to examine the association between different racial and ethnic groups and prescription opioid and other analgesics use before and after lower extremity amputation. We hypothesize prescription opioid and other analgesic use among Black, Hispanic, and Native American US Medicare beneficiaries undergoing lower extremity amputations will be lower compared to White US Medicare beneficiaries. This retrospective cohort study included a 5% national sample of all Medicare beneficiaries from 2011 to 2015 and 15% national sample of fee-for-service Medicare beneficiaries from 2016 to 2018 undergoing nontraumatic, lower extremity amputations. The exposure of interest was racial and ethnic group membership (ie, Black, Hispanic, Native American, White, and others-with others being the combination of the categories Asian and other) as provided in Medicare claims data. Using multivariable generalized estimating equations with a logistic link to account for repeated measurements over time, we estimated the odds of prescription opioid use within 6 months before and after lower extremity amputation across different racial and ethnic groups separately, adjusting for sociodemographic and health status factors (eg, Elixhauser index). Adjusted odds ratios (aORs) and 95% confidence intervals (95% CI) were reported. Among 16,068 eligible beneficiaries who underwent major and minor amputations (mean age = 65.1 ± 12.7 years; female = 36.1%), 10,107 (62.9%) were White, 3462 (21.5%) were Black, 1959 (12.2%) were Hispanic, 247 (1.5%) were Native American, and 151 (2.9%) were beneficiaries of other races. During the 6 months before lower extremity amputation, Hispanic beneficiaries (aOR, 0.71, 95% CI, 0.65-0.78) and beneficiaries of other races (aOR, 0.60, 95% CI, 0.47-0.76) had significantly lower odds of using prescription opioids compared to White beneficiaries. Similarly, Hispanic beneficiaries (aOR, 0.78, 95% CI, 0.71-0.84) and beneficiaries of other races (aOR, 0.63, 95% CI, 0.51-0.78) were associated with lower odds of opioid use in the 6 months after amputation compared to White beneficiaries. Among fee-for-service Medicare beneficiaries, Hispanic and other (eg, Asian) fee-for-service Medicare beneficiaries had lower odds of prescription opioid use than their White counterparts before and after nontraumatic, lower extremity amputations. Efforts to determine the underlying reasons are needed to ensure equitable health care access.

Frailty, Specialized Care, and Sociodemographic Factors: Disparities in Oral Pharmacotherapy Class Utilization Among Medicare Part D Beneficiaries With Overactive Bladder in the United States

ObjectivesTo describe the prevalence of frailty among Medicare beneficiaries with overactive bladder (OAB), analyze oral therapy patterns, and examine potential disparities in treatment. MethodsThis retrospective cohort study utilized the 20% Research Identifiable File Medicare Part D prescription claims dataset (2013-2018). Using the Claims-Based Frailty Index (CFI), Medicare beneficiaries ≥65 years old with OAB were categorized as not frail (CFI <0.15), prefrail (0.15 ≤CFI <0.25), and frail (CFI >0.25). Logistic regression models assessed associations between frailty and pharmacotherapy utilization. ResultsAmong 111,761 patients (15.8% of the OAB cohort) receiving oral pharmacotherapy (anticholinergic oral medications or mirabegron), 71% were women, 83% were White, and 11.9% were frail. After controlling for age, co-payments and dual eligibility status, frail status (OR 1.16; 95% CI [1.09 - 1.24]), urology (OR 2.05 (95% CI [1.94 - 2.16]) or gynecology (OR 1.74; 95% CI [1.6 - 1.9]) prescribers and residing in the Southern United States (OR 1.53; CI [1.49 - 1.61]) were associated with higher likelihood of mirabegron utilization. Black (OR 0.79; 95% CI ([0.74 - 0.85]) and American Indian/Alaska Native (OR 0.54, 95% CI ([0.39 - 0.74]) patients were less likely to utilize mirabegron than White beneficiaries. ConclusionFrail beneficiaries and those with urology and gynecology prescribers showed higher likelihoods of beta-3 agonist utilization. Despite adjustments, Black and AI/AN patients were less likely to fill mirabegron prescriptions, suggesting disparities in treatment. Our findings highlight the need for policies, interventions, and initiatives to promote equitable OAB oral therapy utilization in vulnerable populations.

Antiretroviral Therapy Use and Disparities Among Medicare Beneficiaries with HIV.

Antiretroviral therapy (ART) is recommended for all people with HIV. Understanding ART use among Medicare beneficiaries with HIV is therefore critically important for improving quality and equity of care among the growing population of older adults with HIV. However, a comprehensive national evaluation of filled ART prescriptions among Medicare beneficiaries is lacking. To examine trends in ART use among Medicare beneficiaries with HIV from 2013 to 2019 and to evaluate whether racial and ethnic disparities in ART use are narrowing over time. Retrospective observational study. Traditional Medicare beneficiaries with Part D living with HIV in 2013-2019. Months of filled ART prescriptions each year. Compared with beneficiaries not on ART, beneficiaries on ART were younger, less likely to be Black (41.6% vs. 47.0%), and more likely to be Hispanic (13.1% vs. 9.7%). While the share of beneficiaries who filled ART prescriptions for 10 + months/year improved (+ 0.48 percentage points/year [p.p.y.], 95% CI 0.34-0.63, p < 0.001), 25.8% of beneficiaries did not fill ART for 10 + months in 2019. Between 2013 and 2019, the proportion of beneficiaries who filled ART for 10 + months improved for Black beneficiaries (65.8 to 70.3%, + 0.66 p.p.y., 95% CI 0.43-0.89, p < 0.001) and White beneficiaries (74.8 to 77.4%, + 0.38 p.p.y.; 95% CI 0.19-0.58, p < 0.001), while remaining stable for Hispanic beneficiaries (74.5 to 75.0%, + 0.12 p.p.y., 95% CI - 0.24-0.49, p = 0.51). Although Black-White disparities in ART use narrowed over time, the share of beneficiaries who filled ART prescriptions for 10 + months/year was significantly lower among Black beneficiaries relative to White beneficiaries each year. ART use improved from 2013 to 2019 among Medicare beneficiaries with HIV. However, about 25% of beneficiaries did not consistently fill ART prescriptions within a given year. Despite declining differences between Black and White beneficiaries, concerning disparities in ART use persist.

Racial-Ethnic Disparities in Quality of Care Among Medicaid Beneficiaries With Schizophrenia.

The authors sought to update and expand the evidence on the quality of health care and disparities in care among Medicaid beneficiaries with schizophrenia. Adult beneficiaries of New York State Medicaid with schizophrenia receiving care during 2016-2019 were identified. Composite quality scores were derived from item response theory models by using evidence-based indicators of the quality of mental and general medical health care. Risk-adjusted racial-ethnic differences in quality were estimated and summarized as percentiles relative to White beneficiaries' mean quality scores. The study included 71,013 beneficiaries; 42.8% were Black, 22.9% Latinx, 27.4% White, and 6.9% other race-ethnicity. Overall, 68.8% had a mental health follow-up within 30 days of discharge, and 90.2% had no preventable hospitalizations for chronic obstructive pulmonary disease or asthma. Among beneficiaries receiving antipsychotic medications, medication adherence was adequate for 43.7%. Fourteen indicators for mental and general medical health care quality yielded three composites: two for mental health care (pharmacological and ambulatory) and one for acute mental and general medical health care. Mean quality of pharmacological mental health care for Black and Latinx beneficiaries was lower than for White beneficiaries (39th and 44th percentile, respectively). For Black beneficiaries, mean quality of ambulatory mental health care was also lower (46th percentile). In New York City, Black beneficiaries received lower-quality care in all domains. The only meaningful group difference in the quality of acute mental and general medical health care indicated higher-quality care for individuals with other race-ethnicity. Disparities in the quality of Medicaid-financed health care persist, particularly for Black beneficiaries. Regional differences merit further attention.

Decomposition analysis of racial and ethnic differences in receipt of immediate postpartum, long-acting, reversible, and permanent contraception

ObjectivesThis study aimed to determine the factors contributing to racial and ethnic disparities in the use of immediate postpartum, long-acting reversible contraception (IPP LARC) and permanent contraception among Medicaid recipients. Study designWe conducted a cross-sectional study using 3 years of national Medicaid claims data to examine the rates of IPP LARC use alone and a composite measure of postpartum permanent contraception and IPP LARC within 7 days of delivery by race and ethnicity. We used a Blinder–Oaxaca model to quantify the extent to which medical complexity, age, rurality, mode of delivery, and year explained differences in outcomes among different minoritized groups in comparison to non-Hispanic White women. ResultsOur study sample contained 1,729,663 deliveries occurring from 2016 through 2018 among 1,605,199 people living in 16 states. IPP LARC use rates were highest among Black (2.2%), followed by American Indian and Alaska Native at 2.1% and Hawaiian/Pacific Islander beneficiaries at 1.9%, Hispanic (all races) at 1.2%, and Asian at 1.0%. IPP LARC was lowest among White beneficiaries (0.8%). Medical complexity, age, rurality, year, and mode of delivery explained only 12.3% of the difference in IPP LARC rates between Black and White beneficiaries. Postpartum permanent contraception was highest among White (7.6%), Hispanic (7.2%), and American Indian and Alaska Native (6.8%), followed by Black (6.3%), Hawaiian/Pacific Islander (5.1%) and lowest among Asian women (4.1%). When we examined the use of IPP LARC or postpartum permanent contraception together, these same factors explained 94.4% of the differences between Black and White beneficiaries. ConclusionsWhile differences in the use of IPP LARC by race and ethnicity were identified, our findings suggest that overall use of inpatient highly effective contraception are similar across racial and ethnic groups. ImplicationsWhen IPP LARC and postpartum permanent contraception are examined jointly, their use is similar across racial and ethnic groups.

Impact of comprehensive medication reviews on potentially inappropriate medication discontinuation in Medicare beneficiaries.

The use of potentially inappropriate medications (PIMs) is associated with increased risk of hospitalizations and emergency room visits and varies by racial and ethnic subgroups. Medicare's nationwide medication therapy management (MTM) program requires that Part D plans offer an annual comprehensive medication review (CMR) to all beneficiaries who qualify, and provides a platform to reduce PIM use. The objective of this study was to assess the impact of CMR on PIM discontinuation in Medicare beneficiaries and whether this differed by race or ethnicity. Retrospective cohort study of community-dwelling Medicare Part D beneficiaries ≥66 years of age who were eligible for MTM from 2013 to 2019 based on 5% Medicare fee-for-service claims data linked to the 100% MTM data file. Among those using a PIM, MTM-eligible CMR recipients were matched to non-recipients via sequential stratification. The probability of PIM discontinuation was estimated using regression models that pooled yearly subcohorts accounting for within-beneficiary correlations. The most common PIMs that were discontinued after CMR were reported. We matched 24,368 CMR recipients to 24,368 CMR non-recipients during the observation period. Median age was 74-75, 35% were males, most were White beneficiaries (86%-87%), and the median number of PIMs was 1. In adjusted analyses, CMR receipt was positively associated with PIM discontinuation (adjusted relative risk [aRR]: 1.26, 95% CI: 1.20-1.32). There was no evidence of differential impact of CMR by race or ethnicity. The PIMs most commonly discontinued after CMR were glimepiride, zolpidem, digoxin, amitriptyline, and nitrofurantoin. Among Medicare beneficiaries who are using a PIM, CMR receipt was associated with PIM discontinuation, suggesting that greater CMR use could facilitate PIM reduction for all racial and ethnic groups.

Racial and ethnic disparities related to the Medicare Part D Medication Therapy Management Program.

Medicare's Part D Medication Therapy Management (MTM) programs serve approximately 4.5 million eligible beneficiaries. Prior research suggested that the thresholds to enter Part D MTM programs would disproportionately favor White beneficiaries compared with Black or Hispanic beneficiaries. This article summarizes those initial studies and compares the results with more recent analyses of racial and ethnic differences in MTM program enrollment, which, in general, show higher odds of MTM enrollment for minority beneficiaries compared with White beneficiaries. Disparities in the utilization of comprehensive medication review (CMR), a core MTM service, are also discussed. Although trends vary, disparities exist for various minority groups. For example, Black beneficiaries and Hispanic beneficiaries are less likely to be offered a CMR compared with White beneficiaries. Additionally, minority (Asian, Hispanic, and North American Native) beneficiaries are less likely to receive a CMR after being offered the service compared with White beneficiaries. Black, Hispanic, and Asian beneficiaries are more likely than White beneficiaries to have a longer duration between MTM enrollment and CMR offer. There is also a distinct difference in the type of pharmacist (ie, plan pharmacist, MTM vendor pharmacist, or community pharmacist) completing the CMR for certain racial and ethnic groups. For example, compared with White beneficiaries, Black beneficiaries were less likely to receive a CMR from a community pharmacist, whereas Asian beneficiaries were more likely.

Demographic and Systemic Risk Factors for Persistent Corneal Edema Following Cataract Surgery in Patients With and Without Diabetes

PurposeTo identify risk factors associated with the development of corneal edema (CE) and the need for corneal transplantation following cataract surgery. DesignRetrospective cohort study. MethodsSetting: Nation-wide sample of Medicare beneficiaries from 2011-2015. Study PopulationMedicare beneficiaries aged over 65 years who received cataract surgery between 2011-2014 with at least 1 year of continuous follow-up. Data was retrieved from the Denominator and Physician Supplier Part B file from the Center for Medicare and Medicaid Services. Main Outcome(s) and Measure(s)The main outcome was the association between demographic characteristics (e.g. age, sex, race/ethnicity) and systemic factors including diabetes status, hypertension, and tobacco use on the incidence of CE and the subsequent need for corneal transplantation following cataract surgery. ResultsAmong 187,746 beneficiaries, 67,734 had diabetes and 120,012 did not. Beneficiaries with diabetes were more likely to develop CE compared to those without (Odds ratio [OR] 1.19, 95% Confidence Interval [CI] [1.02-1.40]). Compared to those aged 65-74, beneficiaries aged 75-84 and over 85 were more likely to develop CE (OR 1.29 [1.09-1.52]) and OR 1.96 [1.55-2.46], respectively). Asian (OR 2.42 [1.66-3.40]), Hispanic (OR 2.60 [1.73-3.74]), and North American Native (OR 3.59 [1.78-6.39]) race was associated with increased likelihood of developing CE. North American Native beneficiaries had higher risk of requiring corneal transplantation compared to White beneficiaries (OR 9.30 [2.26-25.31]). Female sex decreased likelihood of requiring corneal transplantation post-operatively (OR 0.56 [0.36-0.87]). Amongst those with diabetes, the presence of proliferative diabetic retinopathy increased the likelihood of developing CE (OR 1.94 [1.05-3.39]). ConclusionOlder age, diabetes, and non-White race elevate the risk of CE following cataract surgery, with race incurring the highest risk. Further research is needed to understand the factors underlying the significantly increased risk of CE in racial and ethnic minorities within the United States.

Comprehensive Medication Review Completion Rates and Disparities After Medicare Star Rating Measure

Comprehensive medication reviews (CMRs) are offered to qualifying US Medicare beneficiaries annually to optimize medication regimens and therapeutic outcomes. In 2016, Medicare adopted CMR completion as a Star Rating quality measure to encourage the use of CMRs. To examine trends in CMR completion rates before and after 2016 and whether racial, ethnic, and socioeconomic disparities in CMR completion changed. This observational study using interrupted time-series analysis examined 2013 to 2020 annual cohorts of community-dwelling Medicare beneficiaries aged 66 years and older eligible for a CMR as determined by Part D plans and by objective minimum eligibility criteria. Data analysis was conducted from September 2022 to February 2024. Adoption of CMR completion as a Star Rating quality measure in 2016. CMR completion modeled via generalized estimating equations. The study included a total of 561 950 eligible beneficiaries, with 253 561 in the 2013 to 2015 cohort (median [IQR] age, 75.8 [70.7-82.1] years; 90 778 male [35.8%]; 6795 Asian [2.7%]; 24 425 Black [9.6%]; 7674 Hispanic [3.0%]; 208 621 White [82.3%]) and 308 389 in the 2016 to 2020 cohort (median [IQR] age, 75.1 [70.4-80.9] years; 126 730 male [41.1%]; 8922 Asian [2.9%]; 27 915 Black [9.1%]; 7635 Hispanic [2.5%]; 252 781 White [82.0%]). The unadjusted CMR completion rate increased from 10.2% (7379 of 72 225 individuals) in 2013 to 15.6% (14 185 of 90 847 individuals) in 2015 and increased further to 35.8% (18 376 of 51 386 individuals) in 2020, in part because the population deemed by Part D plans to be MTM-eligible decreased by nearly half after 2015 (90 487 individuals in 2015 to 51 386 individuals in 2020). Among a simulated cohort based on Medicare minimum eligibility thresholds, the unadjusted CMR completion rate increased but to a lesser extent, from 4.4% in 2013 to 12.6% in 2020. Compared with White beneficiaries, Asian and Hispanic beneficiaries experienced greater increases in likelihood of CMR completion after 2016 but remained less likely to complete a CMR. Dual-Medicaid enrollees also experienced greater increases in likelihood of CMR completion as compared with those without either designation, but still remained less likely to complete CMR. This study found that adoption of CMR completion as a Star Rating quality measure was associated with higher CMR completion rates. The increase in CMR completion rates was achieved partly because Part D plans used stricter eligibility criteria to define eligible patients. Reductions in disparities for eligible Asian, Hispanic, and dual-Medicaid enrollees were seen, but not eliminated. These findings suggest that quality measures can inform plan behavior and could be used to help address disparities.

Receipt of rheumatology care and lupus-specific labs among young adults with systemic lupus erythematosus: A US Medicare retention in care cohort study.

In systemic lupus erythematosus, poor disease outcomes occur in young adults, patients identifying as Black or Hispanic, and socioeconomically disadvantaged patients. These identities and social factors differentially shape care access and quality that contribute to lupus health disparities in the US. Thus, our objective was to measure markers of care access and quality, including rheumatology visits (longitudinal care retention) and lupus-specific serology testing, by race and ethnicity, neighborhood disadvantage, and geographic context. This cohort study used a geo-linked 20% national sample of young adult Medicare beneficiaries (ages 18-35) with lupus-coded encounters and a 1-year assessment period. Retention in lupus care required a rheumatology visit in each 6-month period, and serology testing required ≥1 complement or dsDNA antibody test within the year. Multivariable logistic regression models were fit for visit-based retention and serology testing to determine associations with race and ethnicity, neighborhood disadvantage, and geography. Among 1,036 young adults with lupus, 39% saw a rheumatologist every 6months and 28% had serology testing. White beneficiaries from the least disadvantaged quintile of neighborhoods had higher visit-based retention than other beneficiaries (64% vs 30%-60%). Serology testing decreased with increasing neighborhood disadvantage quintile (aOR 0.80; 95% CI 0.71, 0.90) and in the Midwest (aOR 0.46; 0.30, 0.71). Disparities in care, measured by rheumatology visits and serology testing, exist by neighborhood disadvantage, race and ethnicity, and region among young adults with lupus, despite uniform Medicare coverage. Findings support evaluating lupus care quality measures and their impact on US lupus outcomes.

Antihypertensive medication persistence and adherence among non-Hispanic Asian US patients with hypertension and fee-for-service Medicare health insurance.

Less than 50% of non-Hispanic Asian adults taking antihypertensive medication have controlled blood pressure. We compared non-persistence and low adherence to antihypertensive medication between non-Hispanic Asian and other race/ethnicity groups among US adults ≥66 years who initiated antihypertensive medication between 2011 and 2018 using a 5% random sample of Medicare beneficiaries (non-Hispanic Asian, n = 2,260; non-Hispanic White, n = 56,000; non-Hispanic Black, n = 5,792; Hispanic, n = 4,212; and Other, n = 1,423). Non-persistence was defined as not having antihypertensive medication available to take in the last 90 of 365 days following treatment initiation. Low adherence was defined as having antihypertensive medication available to take on <80% of the 365 days following initiation. In 2011-2012, 2013-2014, 2015-2016 and 2017-2018, the proportion of non-Hispanic Asian Medicare beneficiaries with non-persistence was 29.1%, 25.6%, 25.4% and 26.7% (p-trend = 0.381), respectively, and the proportion with low adherence was 58.1%, 54.2%, 53.4% and 51.6%, respectively (p-trend = 0.020). In 2017-2018, compared with non-Hispanic Asian beneficiaries, non-persistence was less common among non-Hispanic White beneficiaries (risk ratio 0.74 [95%CI, 0.64-0.85]), non-Hispanic Black beneficiaries (0.80 [95%CI 0.68-0.94]) and those reporting Other race/ethnicity (0.68 [95%CI, 0.54-0.85]) but not among Hispanic beneficiaries (1.04 [95%CI, 0.88-1.23]). Compared to non-Hispanic Asian beneficiaries, non-Hispanic White beneficiaries and beneficiaries reporting Other race/ethnicity were less likely to have low adherence to antihypertensive medication (relative risk 0.78 [95%CI 0.72-0.84] and 0.84 [95%CI 0.74-0.95], respectively); there was no association for non-Hispanic Black or Hispanic beneficiaries. Non-persistence and low adherence to antihypertensive medication were more common among older non-Hispanic Asian than non-Hispanic White adults.

Abstract 48: Racial and Ethnic Disparities in Cardiovascular Multimorbidity Progression Among Older United States Adults

Introduction: There is a knowledge gap in the potential unequal burden and progression of cardiovascular multimorbidity. Understanding the progression of cardiovascular multimorbidity and recognizing racial and ethnic disparities are needed to develop effective strategies to achieve health equity. Our objective is to investigate racial and ethnic disparities in the development and progression of cardiovascular multimorbidity among older adults in the United States and estimate relative life expectancies among patients with severe multimorbidity. Hypothesis: We hypothesized that life expectancy among older adults with severe cardiovascular multimorbidity is inversely related to the number of comorbid conditions and varies by race and ethnicity. Methods: Repeated cross-sectional cohort study of inpatient, outpatient, and carrier claims for a 5% nationwide Medicare sample. We included Medicare beneficiaries aged 65 or older enrolled in Medicare Fee-For-Service program from 2010 to 2020 and living in the continental United States. Multistate life table models were employed to estimate cardiovascular disease (CVD) progression and total life expectancies from ages 65 to 85 years. Progression probabilities and life expectancies were adjusted for age, non-cardiovascular comorbidities, and Medicaid dual eligibility. A microsimulation approach was utilized to derive life tables, and bootstrapping was used to estimate variability. The primary outcome was the development and progression of cardiovascular multimorbidity, defined by the number of major cardiovascular conditions (atrial fibrillation, acute myocardial infarction, heart failure, stroke, and chronic ischemic heart disease). Comorbidities were assessed using validated algorithms based on diagnostic codes billed over a 1-year lookback period, and beneficiaries were followed forward from their index date. Results: Of 2,189,633 beneficiaries, the median age was 69, median follow-up duration was 6 years. The cohort mainly consisted of individuals who are Non-Hispanic White (84.4%, n=1,848,410), followed by individuals who are Non-Hispanic Black (8.2%, n=179,694) and individuals from other racial or ethnic groups (7.4%, n=161,529. Non-Hispanic Black beneficiaries had higher odds of multimorbidity progression compared to Non-Hispanic White beneficiaries. Specifically, those initially with one CVD had elevated odds of developing multiple severe CVDs (OR range: 1.02-1.09). Furthermore, they generally had higher odds of progressing to a greater burden of CVD multimorbidity (OR range: 1.00-1.25). Conclusions: These findings suggest persistent racial and ethnic disparities in cardiovascular multimorbidity progression, identifying a potentially important target for the promotion of health equity.

Bone Density Screening Rates Among Medicare Beneficiaries: An Analysis with a focus on Asian Americans.

To report osteoporosis screening utilization rates among Asian American (AsA) populations in the USA. We retrospectively assessed the use of dual-energy X-ray absorptiometry (DXA) screening using the Medicare 5% Research Identifiable Files. Using Current Procedural Terminology (CPT) codes indicative of a DXA scan, we identified patients recommended for DXA screening according to the ACR-SPR-SSR Practice Parameters (females ≥ 65 years, males ≥ 70 years). Sociodemographic factors and their association with screening were evaluated using chi-square tests. There were 80,439 eligible AsA beneficiaries, and 12,102 (15.1%) received osteoporosis screening. DXA rate for women was approximately four times greater than the rate for men (19.8% vs. 5.0%; p < 0.001). AsA beneficiaries in zip codes with higher mean household income (MHI) were more likely to have DXA than those in lower MHI areas (17.6% vs. 14.3%, p < 0.001). AsA beneficiaries aged < 80 were more likely to receive DXA (15.5%) than those aged ≥ 80 (14.1%, p < 0.001). There were 2,979,801 eligible non-AsA beneficiaries, and 496,957 (16.7%) received osteoporosis screening during the study period. Non-Hispanic white beneficiaries had the highest overall screening rate (17.5%), followed by North American Native (13.0%), Black (11.8%), and Hispanic (11.1%) beneficiaries. Comparing AsA to non-AsA populations, there were significantly lower DXA rates among AsA beneficiaries when controlling for years of Medicare eligibility, patient age, sex, location, and mean income (p < 0.001). We found lower than expected DXA screening rates for AsA patients. A better understanding of the barriers and facilitators to AsA osteoporosis screening is needed to improve patient care.

Elective Joint Replacement Among Medicaid Beneficiaries: Utilization and Postoperative Adverse Events by Racial and Ethnic Groups.

Hip and knee replacement have been marked by racial and ethnic disparities in both utilization and postoperative adverse events among Medicare beneficiaries, but limited knowledge exists regarding racial and ethnic differences in joint replacement care among Medicaid beneficiaries. To close this gap, this study used Medicaid claims in 2018 and described racial and ethnic differences in the utilization and postoperative adverse events of elective joint replacements among Medicaid beneficiaries. Among the 2,260,272 Medicaid beneficiaries, 5987 had an elective joint replacement in 2018. Asian (0.05%, 95% confidence interval [CI]: 0.03%-0.07%) and Hispanic beneficiaries (0.12%, 95% CI: 0.07%-0.18%) received joint replacements less frequently than American Indian and Alaska Native (0.41%, 95% CI: 0.27%-0.55%), Black (0.33%, 95% CI: 0.19%-0.48%), and White (0.37%, 95% CI: 0.25%-0.50%) beneficiaries. Black patients demonstrated the highest probability of 90-day emergency department visits (34.8%, 95% CI: 32.7%-37.0%) among all racial and ethnic groups and a higher probability of 90-day readmission (8.0%, 95% CI: 6.9%-9.0%) than Asian (3.4%, 95% CI: 0.7%-6.0%) and Hispanic patients (4.4%, 95% CI: 3.4%-5.3%). These findings indicate evident disparities in postoperative adverse events across racial and ethnic groups, with Black patients demonstrating the highest probability of 90-day emergency department visits. This study represents an initial exploration of the racial and ethnic differences in joint replacement care among Medicaid beneficiaries and lay the groundwork for further investigation into contributing factors of the observed disparities.