Race/ethnic disparities in utilization of lifesaving technologies by medicare ischemic heart disease beneficiaries
Race/ethnic disparities in utilization of lifesaving technologies by medicare ischemic heart disease beneficiaries
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DOI：
10.1097/01.mlr.0000156864.80880.aa
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发表时间：
2005-04-01
期刊：
影响因子：
3
通讯作者：
Urato, C
中科院分区：
文献类型：
--
作者：
Cromwell, J;McCall, NT;Urato, C
目的：本研究的目的是解释老年缺血性心脏病（IHD）患者在住院、高科技诊断和血运重建服务的利用以及死亡率方面的种族/民族差异。设计：1997年所有A部分医院和B部分医生提供的因IHD入院的老年患者的纵向医疗保险索赔数据库用于构建入院、利用、以及白人、黑人、亚洲人、西班牙裔和美洲印第安人的死亡率。Z分数用于在99%的置信水平下测试白人和少数民族之间的比率差异。Logistic和比例风险模型用于预测血运重建的可能性及其对出院后21/2年种族/民族生存率的影响。设置：本研究的设置是由所有门诊B部分门诊护理提供者补充的急性医院。患者/参与者：参与者包括1997年入院时被确定为IHD的所有70万名65岁以上的医疗保险受益人。测量和主要结果：白人因IHD入院的可能性比黑人高26%，比亚洲人高50%，比美洲印第安人高5%，但比西班牙裔低3%。一旦入院，老年黑人和美洲印第安人接受侵入性诊断和手术血运重建的频率远低于白人（P < 0.01），尽管黑人和白人一样有可能被送入心脏直视医院。在控制其他因素的情况下，白人通过41%的时间进行血运重建将其21/2年死亡率降低了20%。由于血运重建的比率和收益比白人低得多，黑人仅获得11%的收益。亚洲人和西班牙裔人比白人更容易接受血运重建，但收益低于whites from the procedure.Conclusions：尽管有类似的医疗保险覆盖范围，老年人的利用率和IHD死亡率显着不同，不仅白人和少数民族之间，但在少数民族群体本身。需要对医生和患者进行一次具有全国代表性的大规模调查，以区分全系统范围内的“转诊失败”和患者“厌恶手术”，作为手术干预率较低的解释。
Objective: The objective of this study was to explain race/ethnic disparities in hospitalizations, utilization of high-technology diagnostic and revascularization services, and mortality of elderly ischemic heart disease (IHD) patients.Design: A longitudinal Medicare claims database of all Part A hospital and Part B physician services provided elderly patients admitted for IHD in 1997 is used to construct admission, utilization, and mortality rates for whites and blacks, Asians, Hispanics, and American Indians. Z-scores are used to test differences in rates between whites and minorities at the 99% confidence level. Logistic and proportional hazard models are used to predict the likelihood of revascularization and its effects on race/ethnic survival 21/2 years postdischarge.Setting: The setting of this study was an acute hospital supplemented by all ambulatory Part B outpatient providers of care.Patients/Participants: Participants included all 700,000 age 65 + Medicare beneficiaries in fee-for-service identified with IHD as a primary diagnosis on admission in 1997.Measurements and Main Results: Whites were 26% more likely to be admitted for IHD than blacks, 50% more likely than Asians, 5% more than American Indians, but 3% less likely than Hispanics. Once admitted, elderly blacks and American Indians undergo invasive diagnostic and surgical revascularization far less often than whites (P < 0.01), although blacks are equally as likely as whites to be admitted to an open heart hospital. Controlling for other factors, whites reduce their 21/2-year mortality by 20% by undergoing revascularization 41% of the time. Blacks gain only 11% as a result of much lower rates and gains to revascularization than whites. Asians and Hispanics were slightly more likely than whites to undergo revascularization but gain less than whites from the procedure.Conclusions: Despite having similar Medicare health insurance coverage, elderly utilization and IHD mortality rates differ markedly not only between whites and minorities, but within minority groups themselves. A large, nationally representative survey of physicians and patients is needed to distinguish between systemwide "failures to refer" and patient "aversions to surgery" as explanations for lower black rates of surgical interventions.