Quality of Care for White and Hispanic Medicare Advantage Enrollees in the United States and Puerto Rico
Quality of Care for White and Hispanic Medicare Advantage Enrollees in the United States and Puerto Rico
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DOI：
10.1001/jamainternmed.2016.0267
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发表时间：
2016-06-01
影响因子：
39
通讯作者：
Trivedi, Amal N.
中科院分区：
文献类型：
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作者：
Rivera-Hernandez, Maricruz;Leyva, Bryan;Trivedi, Amal N.
重要性医疗保险人群中的医疗质量和结果的地理，种族和民族差异已经得到了很好的记录。关于居住在波多黎各的受益人的数据很少，其中四分之三的人参加了医疗保险优势（MA）。目的确定在美国和波多黎各为白人和西班牙裔MA参加者提供的护理质量。设计、设置和参与者对2011年的MA参加者进行了横断面研究，包括美国的白色参加者（n = 6 289 374）、美国的西班牙裔入组者（n = 795 039）和波多黎各的西班牙裔入组者（n = 267 016）。研究时间为2011年1月1日至2011年12月31日;数据分析于2015年1月19日至2016年1月2日进行。主要结果和指标17个与糖尿病相关的绩效指标（包括血红蛋白A（1c）控制、视网膜眼科检查、低密度脂蛋白胆固醇控制、肾病筛查和血压控制），心血管疾病（包括低密度脂蛋白胆固醇控制、血压控制和心肌梗死后使用β受体阻滞剂）、癌症筛查（结直肠和乳腺），和适当的药物（包括用于慢性阻塞性肺疾病[COPD]的全身性皮质类固醇和支气管扩张剂以及缓解疾病的抗风湿药物）在我们的研究中，在美国和波多黎各的735万MA注册者中，106万（14.4%）是西班牙裔。大约25.1%的西班牙裔MA入学者居住在波多黎各，这比居住在任何州的人都多。对于17项评估指标中的15项，与美国的西班牙裔相比，波多黎各的西班牙裔MA注册者接受的护理更差，表现率的绝对差异范围从糖尿病血压控制的2.2个百分点（P = 0.03）到使用疾病缓解抗风湿药物治疗的31.3个百分点（P <0.01）。波多黎各的西班牙裔MA注册者与美国的西班牙裔MA注册者之间的调整后表现差异在3项指标上超过20个百分点：改善疾病的抗风湿药物疗法的应用（-23.8个百分点[95% CI，-30.9至-16.8]），COPD急性加重患者使用全身性皮质类固醇（-21.3个百分点[95% CI，-27.5至-15.1]），以及COPD急性加重患者使用支气管扩张剂治疗（-22.7个百分点[95% CI，-27.7至-17.6]）结论和相关性我们发现在美国的白色和西班牙裔MA注册者之间的护理有适度的差异，但实质上更差的护理与美国同行相比，波多黎各的注册者。需要作出重大努力，将岛上的保健服务提高到与美国相当的水平。
IMPORTANCE Geographic, racial, and ethnic variations in quality of care and outcomes have been well documented among the Medicare population. Few data exist on beneficiaries living in Puerto Rico, three-quarters of whom enroll in Medicare Advantage (MA).OBJECTIVE To determine the quality of care provided to white and Hispanic MA enrollees in the United States and Puerto Rico.DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study of MA enrollees in 2011 was conducted, including white enrollees in the United States (n = 6 289 374), Hispanic enrollees in the United States (n = 795 039), and Hispanic enrollees in Puerto Rico (n = 267 016). The study was conducted from January 1, 2011, to December 31, 2011; data analysis took place from January 19, 2015, to January 2, 2016.MAIN OUTCOMES AND MEASURES Seventeen performance measures related to diabetes mellitus (including hemoglobin A(1c) control, retinal eye examination, low-density lipoprotein cholesterol control, nephropathy screening, and blood pressure control), cardiovascular disease (including low-density lipoprotein cholesterol control, blood pressure control, and use of a beta-blocker aftermyocardial infarction), cancer screening (colorectal and breast), and appropriate medications (including systemic corticosteroids and bronchodilators for chronic obstructive pulmonary disease [COPD] and disease-modifying antirheumatic drugs).RESULTS Of the 7.35 million MA enrollees in the United States and Puerto Rico in our study, 1.06 million (14.4%) were Hispanic. Approximately 25.1% of all Hispanic MA enrollees resided in Puerto Rico, which was more than those residing in any state. For 15 of the 17 measures assessed, Hispanic MA enrollees in Puerto Rico received worse care compared with Hispanics in the United States, with absolute differences in performance rates ranging from 2.2 percentage points for blood pressure control in diabetes mellitus (P = .03) to 31.3 percentage points for use of disease-modifying antirheumatic drug therapy (P < .01). Adjusted performance differences between Hispanic MA enrollees in Puerto Rico and Hispanic MA enrollees in the United States exceeded 20 percentage points for 3 measures: use of disease-modifying antirheumatic drug therapy (-23.8 percentage points [95% CI, -30.9 to -16.8]), use of systemic corticosteroid in COPD exacerbation (-21.3 percentage points [95% CI, -27.5 to -15.1]), and use of bronchodilator therapy in COPD exacerbation (-22.7 percentage points [95% CI, -27.7 to -17.6]).CONCLUSIONS AND RELEVANCE We found modest differences in care between white and Hispanic MA enrollees in the United States but substantially worse care for enrollees in Puerto Rico compared with their US counterparts. Major efforts are needed to improve care delivery on the island to a level equivalent to the United States.