Session
Structural Racism‚ Health Equity and Aging
APHA 2022 Annual Meeting and Expo
Abstract
Trends in Alzheimerâs disease mortality in the United States, 1999-2020: widening disparities by race and ethnicity
APHA 2022 Annual Meeting and Expo
Background: Increase in geriatric populations in the United States (US) has been associated with rising prevalence of Alzheimerâs disease (AD). We assessed the trends in mortality from AD by race and ethnicity in the US from 1999 through 2020.
Methods: Data were extracted from the CDC WONDER database. The ICD-10 codes- G30.0, G30.1, G30.8, and G30.9, were used to identify AD decedents from 1999 through 2020. Age adjusted mortality rates (AAMR) were abstracted overall, and by race and ethnicity. Trends in AAMR were estimated using a Joinpoint regression model. Annual percentage changes (APC) were derived using Monte Carlo Permutation and 95% confidence intervals (CI) were estimated using the Parametric Method.
Results: A total of 1,872,576 persons died from AD in the US from 1999 to 2020. Mortality trends, overall, have been stable since 2005 (APC=0.6; 95% CI: -2.5, 3.8), with differences observed by race and ethnicity. Recent trends have been stationary among Non-Hispanic Whites (APC=0.6; 95% CI: -2.6, 3.8) and Non-Hispanic Blacks (APC=0.9; 95% CI: -2.7, 4.7) since 2016. However, rates have been increasing by 4.6% per year (95% CI: 3.9, 5.4) among Asians/Pacific Islanders since 2006; by 2.5% per year (95% CI: 1.6, 3.5) among American Indians/Alaska Natives since 1999, and; by 6% per year (95% CI: 4.0, 8.1) among Hispanics since 2012.
Conclusions: AD mortality trends are differentially distributed by race and ethnicity in the US population. Further research into identifying the drivers of AD mortality among racial and ethnic subgroups, would help direct public health intervention efforts.
Abstract
Racial and Ethnic Disparities in the Enrollment of Medicare Medication Therapy Management Programs
APHA 2022 Annual Meeting and Expo
Background: Racial and ethnic disparities have been found in prior literature examining the likelihood of enrollment in Medicare medication therapy management (MTM) programs. However, those studies were based on various scenarios of MTM eligibility criteria because MTM enrollment data were not available. This study tested for potential racial and ethnic disparities in MTM enrollment using recently available MTM data.
Methods: This is a retrospective analysis of data from Medicare A and B claims, MTM Data Files, the Area Health Resources File from 2013-2014 and 2016-2017. A logistic regression was used to adjust for patient and community characteristics when comparing odds of MTM enrollment between racial and ethnic minorities and non-Hispanic Whites. The trend of disparities was analyzed by including in the regression model an interaction term between the dummy variable for a racial/ethnic minority group and the period 2016-2017.
Results: Significant disparities in MTM enrollment were detected between Blacks and Whites among individuals with diabetes in 2013-2014 (OR=0.78, 95% confidence interval [CI]=0.75-0.81). This disparity improved from 2013-2014 to 2016-2017 for Blacks (OR=1.08, 95% CI=1.04-1.11) but persisted in 2016-2017 (OR=0.84, 95% CI=0.81-0.87). A significant disparity was also identified between Blacks and Whites among individuals with hypertension in 2013-2014 (OR=0.92 95% CI=0.89-0.95). There was no significant disparity in MTM enrollment between Blacks and Whites among individuals with hypertension in 2016-2017. In most other cases, racial and ethnic minorities were more likely to be enrolled in MTM. Enrollment for all groups, however, declined from 2013-2014 to 2016- 2017 (OR=0.78, 95% CI=0.75-0.81).
Conclusions: Racial and ethnic disparities in MTM enrollment were found between Blacks and Whites among individuals with diabetes in both periods and among individuals with hypertension in only 2013-2014. As overall enrollment fell over time, concerns about program access remain a relevant research and policy focus for the general population and for minority groups specifically.
Abstract
Racial/Ethnic Disparities in the Enrollment of Medication Therapy Management Programs among Medicare Beneficiaries with Alzheimerâs Disease and Related Dementias
APHA 2022 Annual Meeting and Expo
Background: Previous analysis of policy scenarios reported potential racial/ethnic disparities in eligibility in Medicare Part D Medication Therapy Management (MTM) program. With recently released MTM data, this study aimed to determine if racial/ethnic disparities exist in MTM enrollment among Medicare beneficiaries with Alzheimerâs disease and related dementias (ADRD).
Methods: Medicare claims/records (from 2013-2014 and 2016-2017) linked to the Area Health Resources File were examined. Included individuals were patients with ADRD and diabetes, hypertension, or hyperlipidemia. Racial/ethnic disparities were examined using a logistic regression. Disparities across study periods were compared by estimating a logistic regression model with interaction terms between dummy variables for each racial/ethnic minority group and 2016-2017.
Results: In unadjusted analyses, minorities had higher enrollment proportions than Whites. In 2016-2017, enrollment percentages for non-Hispanic Whites (Whites), Blacks, Hispanics, Asian/Pacific Islanders (Asians), and Others were respectively 14.44%, 16.71%, 19.83%, 16.66%, and 17.78%. In adjusted analyses, Blacks had lower enrollment odds than Whites within all cohorts. For example, in the entire study sample in 2016-2017, Blacks with ADRD had 9% lower odds of MTM enrollment (odds ratio 0.91, 95% confidence interval [CI] =0.86-0.97) than Whites. These disparities decreased over time among the ADRD sample and all sub-groups. For instance, the interaction term between Blacks and 2016-2017 indicated that disparities were lowered by 11% (odds ratio 1.11, 95% CI=1.05-1.16) across study periods among those with ADRD.
Conclusions: Blacks with ADRD and diabetes, hypertension, or hyperlipidemia have lower likelihood of MTM enrollment than Whites. Racial disparities were reduced over time but not eliminated.
Abstract
Impact of Medicare Star Ratings Bonus Payment on Racial and Ethnic Disparities in Medication Utilization Quality
APHA 2022 Annual Meeting and Expo
Background:
Medicare Parts C&D Star Ratings bonus program is promising in addressing racial/ethnic disparities in medication utilization because it rewards plans with better quality. This study evaluated the effects of Star Ratings bonus payment on racial/ethnic disparities in medication utilization quality among Medicare population.
Methods:
Medicare claims linked to Area Health Resources File were analyzed covering the pre-bonus (2010-2011) and post-bonus (2016-2017) periods. The study sample included enrollees in bonus-eligible Medicare Advantage prescription drug (MAPD) plans and bonus-ineligible stand-alone prescription drug plans (PDP) that were matched using a propensity score method. Appropriateness of medication utilization was assessed based on Star Ratings and non-Star Ratings measures developed by Pharmacy Quality Alliance. A difference-in-differences approach was employed by incorporating three-way interaction terms between dummy variables for MAPD enrollment, post-bonus period, and racial/ethnic minorities in multivariable logistic regressions.
Results:
Significant racial/ethnic disparities in appropriate medication utilization were identified for Star Ratings and non-Star Ratings measures. For instance, 24.13% non-Hispanic White (White) patients, 31.16% Black patients, and 31.16% Hispanic patients among MAPD enrollees had inappropriate medication utilization based on Star Ratings measures in 2017. Across periods, Black-White disparities for Star Ratings measures and all measures were, respectively, reduced among MAPD enrollees by 10% more (OR=0.90; 95% CI=0.85-0.95) and by 8% more (OR=0.92; 95% CI=0.88-0.96) than PDP enrollees.
Conclusions:
This study suggests that Star Ratings bonus program was associated with reduced disparities in medication utilization quality between Black and White patients. The findings can inform refinement of Star Ratings program when implementing quality assessment metrics.
Abstract
Improving Equitable Access to Healthcare Services for Adults Aging into Medicare
APHA 2022 Annual Meeting and Expo
Background
Aging adults entering their Initial Enrollment Period (IEP) for Medicare at age 65 face a series of important decisions about their health insurance coverage. The federal Medicare program is complex, and confusing to many people. Coverage choices made without a complete understanding of the various Medicare and related Medicaid programs, lead to inequitable access to healthcare services, poor health outcomes, and financial instability.
Description
Using Electronic Health Records (EHR), healthcare delivery systems have the ability to easily identify consumers as they are entering their Medicare Initial Enrollment Period (IEP). Outreach and education efforts targeting this population can offer personalized insurance coverage review, enrollment assistance, and a discussion of other community resources. This grant funded demonstration project aims to facilitate timely enrollment in all available benefits in a proactive manner.
Lessons Learned
Systematic engagement with the population of adults aging into Medicare has highlighted the patterns of common confusions and organizational failures that lead to healthcare disparities for aging adults. Our assessment of these barriers has created opportunities to articulate advocacy efforts and focused interventions.
Implications
Meaningful and predictable use of data shared between the Center for Medicare and Medicaid Services (CMS) and the Maine State Department of Health and Human Services (DHHS) could reduce the numbers of uninsured or underinsured aging adults. Meaningful use of available data would also reduce redundant or duplicative efforts on the part of advocates.
Using EHR data, healthcare delivery systems can proactively identify the most vulnerable patients as they are entering their Medicare IEP, and intervene to prevent aging adults from experiencing healthcare inequities and financial hardship.
Abstract
The Exposures of Living In a Segregated Suburban Community: Outcomes For Black Elders
APHA 2022 Annual Meeting and Expo
Background: Nassau County, NY, a suburb of New York City, is one of the most racially segregated in the country. Decades of redlining, restrictive covenants, and blockbusting left the Village of Hempstead in Nassau County with disinvestment in its properties and lifelong residents. Residents live with negative effects of segregation like poor health outcomes, high unemployment, and few healthy food options. Residential segregation is considered to be a fundamental cause of health disparities, yet the long-term lived experiences are rarely examined. This study explores how living in a segregated community impacts the perspectives and accumulated health outcomes of elderly Black residents.
Methods: Seven long-time elderly residents of Hempstead were interviewed using semi-structured, open-ended questions that were recorded, transcribed, and analyzed. Salient themes were identified after coding the transcripts and reviewed by the researchers using an iterative process.
Results: Participants identified the toll that these impersonal policies took, including feelings of neglect, as conditions from the past have not improved. Many believed that there was racial progress and unity when they were younger that dissipated over time, resulting in frustration. Participants identified the impact of living through segregation, white flight, gentrification, and limited opportunities on their mental and physical health.
Conclusion: The long-term effects of structural racism in a suburban community continue to influence the lives and health of Black elderly residents. Understanding how these policies continue to reverberate is a necessary component to achieve health equity and social justice.
Abstract
Factors improving and hindering the recruitment of Hispanic/Latinx American older adults in clinical trials in the USA
APHA 2022 Annual Meeting and Expo
Hispanic/Latinx American older adultsâ (HLAoa) participation in clinical trials is fundamental to aging health equity. However, information on strategies for successful recruitment of this population in clinical trials is limited. This study examined facilitators and barriers to recruiting HLAoa in clinical trials.
Two databases (PubMed, EMBASE) were searched for original research articles from inception until March 2022 reporting on recruitment strategies that successfully engaged HLAoa (>=65) in clinical trials in the USA. Two co-authors independently reviewed 1013 studies and identified 31 eligible articles. All assessed strategies recruiting mixed minorities of various age cohorts. Most articles were from cancer clinical trials (38%). The primary facilitating factor identified (41% studies) was to develop dedicated strategies to recruit HLAoa before starting the clinical trial. The second most important factor (34% of studies) was to implement multiple recruitment strategies simultaneously. Partnering with community groups trusted by HLAoa was the third most important facilitating factor identified in 28% of the studies. The primary barrier preventing recruitment of HLAoa in clinical trials was eligibility criteria that unconsciously biased study criteria that often excluded or hindered their participation.
Our study has identified 4 key factors (three facilitators and one barrier) that influence researchersâ ability to recruit HLAoa in clinical trials. Factors identified here may guide researchers to mitigate unconscious biases and improve the participation of HLAoa in clinical trials, leading to more equitable research that does not exclude communities of color.