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

BMJ. 2023 Oct 25:383:e074908. doi: 10.1136/bmj-2023-074908.


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.

MeSH terms

  • Aged
  • Black People
  • Black or African American / statistics & numerical data
  • Delivery of Health Care* / ethnology
  • Delivery of Health Care* / standards
  • Female
  • Healthcare Disparities* / ethnology
  • Healthcare Disparities* / standards
  • Healthcare Disparities* / statistics & numerical data
  • Humans
  • Low-Value Care*
  • Male
  • Medicare* / statistics & numerical data
  • Race Factors
  • Retrospective Studies
  • United States / epidemiology
  • White / statistics & numerical data