1. Unequal Utilization of New Technologies by Race The Use of New Prostate Surgeries (TUNA and TUMT) among Medicare Elderly Beneficiaries Xinhua Yu, PhD, MBBS A. Marshall McBean, MD, MSc Debra S. Caldwell, MS Research Data Assistance Center University of Minnesota Janet A. Anderson Centers for Medicare and Medicaid Services AcademyHealth Annual Research Meeting June 7, 2004

2. Benign Prostate Hypertrophy (BPH) Enlargement of prostate gland Enlargement causes obstruction of outflow of urine and results in symptoms that significantly affect the quality of life BPH affects three out of four men aged 70 or above The prevalence of BPH for Blacks and Whites is not significantly different (Platz EA, Urology 59, 2002)

3. Treatment Surgical: transurethral resection of prostate (TURP) transurethral microwave thermotherapy (TUMT) transurethral needle ablation of prostate (TUNA) Others (laser, electropulvarization, etc.) Medical: Watchful waiting Drugs: alpha-blockers, finasteride

4. Rationale for Study Black elderly Medicare beneficiaries have lower rates of many surgical procedures than Whites TURP is performed 10% more frequently among elderly Whites than among Blacks (Wasson JH, J Urol. 2000 164(4)) New BPH surgeries do not require hospitalization and are not known to have any different side effects or complications than TURP Little is known about the access (use) of new procedures in general, by race, and these new BPH procedures, in particular

5. Objective and Hypothesis Examine racial difference of new BPH surgical procedures (TUMT and TUNA) among elderly Medicare beneficiaries H 0 - Blacks and Whites will receive new BPH surgical procedures at equal rates

6. Data Source/Case Identification 100% Medicare claims and Denominator files from CMS Identified any BPH procedures in Carrier, Inpatient, or Outpatient claim file from 1999-2001 BPH procedure: CPT code: TURP (52601, 52612, 52614); TUMT (53850); TUNA (53852) ICD 9-CM procedure code: TURP (60.29); TUMT (60.96); TUNA (60.97) For procedures done in hospital or hospital out- patient, we matched physician and institution claims to avoid duplication

7. Inclusion Criteria Black and white men only Age ≥ 65 Enrolled in both Medicare Part A and Part B during the study years Not in managed care during the study years No End Stage Renal Disease No history of prostate cancer

8. Study Cohort Total sample size: 140,207 patients % Total US Beneficiaries CountiesWhitesBlacks Overall TUMT 63157%69% TUNA 40946%57% TUMT/TUNA 78364%74% Restricted TUMT 55855%69% TUNA 37845%57% TUMT/TUNA 69063%74%

9. Statistical Analysis Separate analysis for Total U.S. those counties where new procedures were performed and had 10 or more black elderly male beneficiaries Race-specific procedure rates per 10,000 person years Direct standardization for age adjustment Geographic heterogeneity was adjusted using Generalized Estimate Equation model (GEE), Poisson regression were used for adjusted rate ratios

10. Table 1: Age Adjusted BPH Procedure Rates among all U.S. Medicare Beneficiaries, 1999-2001 Rate: per 10,000 person years WhitesBlacks Rate ratio Procedures RateProcedures Rate TURP 111,65543.27,62439.31.10 TUMT 15,4796.05472.82.14 TUNA 4,7131.81891.01.88 TUMT/TUNA 20,1927.87363.82.05

13. Table 2: Age Adjusted Procedure Rates among Medicare Beneficiaries in Procedure Counties, 1999-2001 Rate: per 10,000 person years Whites Blacks Rate ratio Procedures RateProcedures Rate TURP 7133742.9570840.01.07 TUMT 109967.74683.52.23 TUNA 34142.91671.51.93 TUMT/TUNA 148609.26434.42.07

14. Note: Colored areas were restricted counties * Purple color: Procedure performed only in Whites

15. Table 3: White/Black Rate Ratio Adjusted for Geographic Variation among Medicare beneficiaries, 1999-2001 Data were restricted counties CI: confidence interval Procedures Unadjusted Rate Ratio Adjusted Rate Ratio (95% CI)p-value TURP 1.071.10 (1.01,1.20)0.0259 TUMT 2.231.67 (1.48,1.89)<.0001 TUNA 1.931.51 (1.18,1.94)0.0012 TUMT/TUNA 2.071.68 (1.48,1.91)<.0001

16. Conclusion White:Black rate ratio for TURP are consistent with past reports and are an appropriate surrogate for the need for new surgery (RR=1.1) Nationally, elderly Black Medicare beneficiaries were significantly less likely to receive new BPH surgical procedures than Whites (RR=2.1) After adjusting for geographic variation, differences between the races persist (RR=1.7)

17. Discussion Racial difference not due to availability of procedure Severity of BPH Patient preference Cost to patient – future study

18. Acknowledgement Research Data Assistance Center (ResDAC), University of Minnesota Coverage and Analysis Group, Centers for Medicare and Medicaid Services (CMS) Supported by CMS contract CMS 500-01- 0043