Racial differences in low value care among older adult Medicare patients in US health systems: retrospective cohort study

Abstract

Objective: To characterize racial differences in receipt of low value care (services that provide little to no benefit yet have potential for harm) among older Medicare beneficiaries overall and within health systems in the United States.

Design: Retrospective cohort study SETTING: 100% Medicare fee-for-service administrative data (2016-18).

Participants: Black and White Medicare patients aged 65 or older as of 2016 and attributed to 595 health systems in the United States.

Main outcome measures: Receipt of 40 low value services among Black and White patients, with and without adjustment for patient age, sex, and previous healthcare use. Additional models included health system fixed effects to assess racial differences within health systems and separately, racial composition of the health system's population to assess the relative contributions of individual patient race and health system racial composition to low value care receipt.

Results: The cohort included 9 833 304 patients (6.8% Black; 57.9% female). Of 40 low value services examined, Black patients had higher adjusted receipt of nine services and lower receipt of 20 services than White patients. Specifically, Black patients were more likely to receive low value acute diagnostic tests, including imaging for uncomplicated headache (6.9% v 3.2%) and head computed tomography scans for dizziness (3.1% v 1.9%). White patients had higher rates of low value screening tests and treatments, including preoperative laboratory tests (10.3% v 6.5%), prostate specific antigen tests (31.0% v 25.7%), and antibiotics for upper respiratory infections (36.6% v 32.7%; all P<0.001). Secondary analyses showed that these differences persisted within given health systems and were not explained by Black and White patients receiving care from different systems.

Conclusions: Black patients were more likely to receive low value acute diagnostic tests and White patients were more likely to receive low value screening tests and treatments. Differences were generally small and were largely due to differential care within health systems. These patterns suggest potential individual, interpersonal, and structural factors that researchers, policy makers, and health system leaders might investigate and address to improve care quality and equity.

Fig 1

Unadjusted rates of low value service receipt among Black and White Medicare patients attributed to 595 health systems in the United States. CAD=coronary artery disease; CT=computed tomography; DEXA=dual energy x ray absorptiometry; echo=echocardiography; MRI=magnetic resonance imaging; PFT=pulmonary function testing; T3=triiodothyronine

Fig 2

Adjusted differences in low value service receipt between Black and White Medicare patients overall and within health systems. CAD=coronary artery disease; CT=computed tomography; DEXA=dual energy x ray absorptiometry; echo=echocardiography; MRI=magnetic resonance imaging; PFT=pulmonary function testing; T3=triiodothyronine. *Indicates statistical significance of primary model (adjusted Black-White differences overall in study cohort) after correction for multiple testing. Values are presented in percentage points. All estimates are from logistic regression models adjusted for age, sex, and number of ambulatory care visits in 2016 that account for clustering by health system. Purple denotes adjusted Black-White differences (primary models); yellow denotes adjusted within-system Black-White differences in models that also included health system fixed effects. Dots represent estimates; the upper and lower ends of the bars are confidence intervals. Patients were attributed to health systems based on the plurality of primary care visits across 2017 and 2018. See supplementary table 1 for measure definitions