Identifying Racial and Ethnic Disparities in Admissions for Ambulatory Care Sensitive Conditions among Medicare Beneficiaries Presented by Arthur J. Bonito, Ph.D. 1 ; Celia R. Eicheldinger, M.S. 1 ; Arthur A. Meltzer, Ph.D. 2, And Linda G. Greenberg, Ph.D. 3 1 RTI International; 2 CMS; 3 AHRQ Presented at The 2005 Annual Research Meeting of AcademyHealth, Boston, MA, June 28, 2005 RTI International is a trade name of Research Triangle Institute 3040 Cornwallis Road P.O. Box Research Triangle Park, NC Phone

2 Background Limited information and few previously published studies exist on access to care for minority Medicare beneficiaries, other than African Americans, using Medicare administrative claims data. CMS sponsored this project to improve identification of Asians and Hispanics, as well as to examine disparities in health care access and use under Medicare. Avoidable hospitalizations for ACSCs provide one indication of limited access and receipt of less-than- adequate primary care.

3 Ambulatory Care Sensitive Conditions Hospital or Emergency Room (ER) admissions for 15 Ambulatory Care Sensitive Conditions (ACSCs) that include the following : Chronic (5) – chronic lung disease (asthma and COPD), congestive heart failure, seizures, diabetes, and hypertension Acute (8) – cellulitis; bacterial pneumonia; urinary tract infection; ulcers; hypoglycemia; hypokalemia; dehydration; ear, nose, and throat infections Preventable (2) – influenza and malnutrition

4 Study Goals To improve accuracy of racial/ethnic identification of Medicare beneficiaries to include: non-Hispanic White, Black, Hispanic, Asian/Pacific Islander (A/PI), and American Indian/Alaska Native (AI/AN). To identify racial/ethnic disparities in hospital or emergency room admissions for ACSCs.

5 Methods and Data Developed algorithm to more correctly identify Medicare beneficiaries race/ethnicity: Used Spanish and Asian surname lists from US Census. From Medicare enrollment database (EDB), used first and last name, race/ethnicity, language preference and place of residence. Used common first names from web sources. Used Medicare Part A claims for 2002 to estimate hospital and ER admissions for ACSCs. Selected a stratified random sample of 1.96 million FFS Medicare beneficiaries (over-sampling minorities).

6 Data Limitations CMS obtains race/ethnicity data on Medicare beneficiaries from SSA, which categorizes Hispanic as a race code. We present findings for AI/ANs despite under- identification on the EDB. CMS has been working with IHS since 1999 to improve identification of AI/AN beneficiaries. Analyses show small predictable bias.

Medicare FFS Study Sample Race/Ethnicity SampleMedicare FFS NH White 329,95426,779,400 Black 328,246 3,053,618 Hispanic 534, ,664 A/PI 415, ,914 AI/AN 120, ,818 Other/Unknown 231, ,630 TOTAL 1,960,12131,579,044

8 Analysis Approach We examined hospital or ER admissions for each type of ACSC - chronic, acute, preventable, and any. We examined percentages with hospital or ER admission by type of ACSC, race/ethnicity, sex, and age group. The following tables include stacked bar graphs for each type of ACSC by race, sex, and age.

9 Figure 1 Percentage of male Medicare beneficiaries with admissions for chronic ambulatory care sensitive conditions by age group and race/ethnicity: CY 2002

10 Figure 2 Percentage of female Medicare beneficiaries with admissions for chronic ambulatory care sensitive conditions by age group and race/ethnicity: CY 2002

11 Preliminary Results for Chronic ACSCs Across all race/ethnicity groups, women have higher percent of admissions for chronic ACSCs than men. Typically, men and women under age 65 have higher percent of admissions for chronic ACSCs. Among elderly men and women (65 years of age and over), admissions for chronic ACSCs increase with age. A/PI and White beneficiaries have lowest percent of admissions for chronic ACSCs, Blacks and AI/ANs have the highest percent, Hispanics falls in between.

12 Figure 3 Percentage of male Medicare beneficiaries with admissions for acute ambulatory care sensitive condition by age group and race/ethnicity: CY 2002

13 Figure 4 Percentage of female Medicare beneficiaries with admissions for acute ambulatory care sensitive condition by age group and race/ethnicity: CY 2002

14 Preliminary Results for Acute ACSCs Across all race/ethnicity groups, women have higher percent of admissions for acute ACSCs than men. Men and women age 85 and over have highest percent of admissions for acute ACSCs. Among elderly men and women, admissions for acute ACSCs increase with age. A/PI beneficiaries have lowest percent of admissions, Blacks and AI/ANs have the highest, and Whites and Hispanics fall in between.

15 Figure 5 Percentage of male Medicare beneficiaries with admissions for preventable ambulatory care sensitive condition by age group and race/ethnicity: CY 2002

16 Figure 6 Percentage of female Medicare beneficiaries with admissions for preventable ambulatory care sensitive conditions by age group and race/ethnicity: CY 2002

17 Preliminary Results for Preventable ACSCs Across all race/ethnicity groups, women have a higher percent of admissions for preventable ACSCs than men. Typically, among men and women – ages 85 and over and under 65 – have the highest percent of admissions for preventable ACSCs. Typically, among elderly men and women, admissions for preventable ACSCs increase with age. A/PI beneficiaries have lowest percent of admissions, Blacks and AI/ANs have the highest, and Whites and Hispanics fall in between.

18 Figure 7 Percentage of male Medicare beneficiaries with admissions for any ambulatory care sensitive condition by age group and race/ethnicity: CY 2002

19 Figure 8 Percentage of female Medicare beneficiaries with admissions for any ambulatory care sensitive condition by age group and race/ethnicity: CY 2002

20 Preliminary Results for any ACSCs Across all race/ethnicity groups, women have higher percent of admissions for all ACSCs combined than men. Men and women ages 85 and over have highest percent of admissions for all ACSCs combined. Among elderly men and women, admissions for all ACSCs combined increase with age. A/PI beneficiaries have lowest percent of admissions, Blacks and AI/ANs have the highest, and Whites and Hispanics fall in between.

21 Summary of Preliminary Results There is considerable consistency across the 15 individual ACSCs and the four grouped -- chronic, acute, preventable and any -- with respect to racial/ethnic differences in the level of hospital or ER admissions, with age and sex controlled. Black and AI/AN beneficiaries have the highest levels of ACSC hospital or ER admissions. A/PI beneficiaries have the lowest level of ACSC hospital or ER admissions. Hispanic and White beneficiaries typically occupy the middle ground, with lower levels of ACSC hospital or ER admissions than Black and AI/AN, but higher than A/PI.

22 Conclusions The improved race/ethnicity variable indicates sizeable and consistent differences in admissions for ACSCs, suggesting differences in access by some minority groups to timely and appropriate primary care services. More accurate coding for Hispanics and A/PIs allows a unique opportunity to increase our knowledge of disparities in health care use and outcomes. Additional research is needed, including multivariate analysis to adjust for differences in SES, health status, disease levels, as well as hospital, ER, outpatient, and ambulatory care service use.