Improving identification of Hispanic males in Medicare: use of surname matching

OBJECTIVES: Medicare administrative and claims files maintained by the Centers for Medicare and Medicaid Services (CMS) are frequently used to examine racial and ethnic disparities in healthcare use. However, identification of Hispanic ethnicity for beneficiaries in the Medicare claims files is problematic, greatly limiting the use of these administrative data for examining race/ethnicity differences. This article reports on 2 studies assessing the effectiveness of a Hispanic surname match for improving the accuracy of race/ethnicity codes for elderly males in the Medicare data sets. METHODS: Study 1 used survey data to compare a Medicare race code + Spanish surname composite indicator to self-identification as Hispanic. Study 2 used Medicare administrative files and U.S. Census 2000 data to identify how well the Medicare race code alone and the Medicare race code + Spanish surname composite indicator compared with estimates obtained from census data for 16 U.S. counties dispersed across 5 states. RESULTS: Using self-identification as the gold standard, including the Spanish surname match increased accuracy for Hispanics and whites compared with the Medicare race code alone. The Spanish surname match also dramatically improved the Medicare code's estimation of elderly Hispanic and white males compared with county-level census data. CONCLUSIONS: Augmenting the Medicare race code with a match to Spanish surnames yields substantial improvement in the identification of elderly Hispanic and white non-Hispanic male Medicare beneficiaries. Using surname information to supplement the Medicare race code could greatly enhance researchers' ability to examine healthcare equity.     

Ambulatory care sensitive hospitalizations and emergency visits: experiences of Medicaid patients using federally qualified health centers

BACKGROUND: Federally Qualified Health Centers (FQHCs) serve as regular sources of preventive and primary care for low-income families within their communities and are key parts of the health care safety net. OBJECTIVES: Compare admissions and emergency room visits for ambulatory care sensitive conditions (ACSCs) among Medicaid beneficiaries relying on FQHCs to other Medicaid beneficiaries. RESEARCH DESIGN: Retrospective analysis of 1992 Medicaid claims data for 48,738 Medicaid beneficiaries in 24 service areas across five states. SUBJECTS: Medicaid beneficiaries receiving more than 50% of their preventive and primary care services from FQHCs are compared with Medicaid beneficiaries receiving outpatient care from other providers in the same areas. Exclusions-managed care enrollees, beneficiaries more than age 65, dual eligibles (Medicaid and Medicare), and institutionalized populations. MEASURES: Admissions and emergency room (ER) visits for a set of chronic and acute conditions, known in the literature as ambulatory care sensitive conditions (ACSCs). RESULTS: Medicaid beneficiaries receiving outpatient care from FQHCs were less likely to be hospitalized (1.5% vs. 1.9%, P < 0.007) or seek ER care (14.9% vs. 15.7%, P < 0.02) for ACSCs than the comparison group. Controlling for case mix and other demographic variables, the odds ratios were, for hospitalizations, OR, 0.80; 95% CI, 0.67 to 0.95; P < 0.01, and for ER visits, OR, 0.87; 95% CI, 0.82 to 0.92; P < 0.001. CONCLUSIONS: Having a regular source of care such as FQHCs can significantly reduce the likelihood of hospitalizations and ER visits for ACSCs. If the reported differentials in ACSC admissions and ER visits were consistently achieved for all Medicaid beneficiaries, substantial savings might be realized.     

Racial disparities in the development of dysphagia after stroke: further evidence from the Medicare database

Bussell SA, González-Fernández M. Racial disparities in the development of dysphagia after stroke: further evidence from the Medicare database.

Objective

To describe the relationship between minority race/ethnicity and dysphagia after stroke in a national sample. Unlike the multiple studies that have examined racial disparities in stroke incidence, risk factors, outcomes, and quality of care, the influence of race or ethnicity on dysphagia after stroke has been understudied. We hypothesized that the odds of dysphagia would be higher for Asians compared with Caucasians in the United States given the results of a previous study in the U.S.

Design

Observational study.

Setting

Conducted using the U.S. National Medicare Medical Provider Analysis and Review Data.

Participants

Medicare beneficiaries admitted in 2007 with a stroke diagnosis.

Intervention

We selected 382,959 cases with cerebrovascular disease codes with self-identified race/ethnicity of Caucasian, African American, Asian, Hispanic, Native American, or other/unknown. Cases had a diagnosis of cerebrovascular disease, defined as International Classification of Disease, Ninth Revision codes 430 to 438.9. Self-reported race/ethnicity was recorded in the following categories: Caucasian, African American, Asian, Hispanic, Native American, and other/unknown.

Main Outcome Measure

Dysphagia after stroke as coded in the data.

Results

The adjusted odds ratio (OR) for poststroke dysphagia was higher for Asians and other minority groups compared with Caucasians (Asian: OR, 1.73; 95% confidence interval [CI], 1.60–1.88; Hispanic: OR, 1.50; 95% CI, 1.39–1.63; African American: OR, 1.42; 95% CI, 1.37–1.47; unknown/other: OR, 1.27; 95% CI, 1.16–1.38; Native American; OR, 1.44; 95% CI, 1.22–1.69).

Conclusions

Our findings confirm previous research suggesting an association between Asian race and dysphagia after stroke while adding evidence for increased odds in other racial/ethnic minority groups.     

Racial disparities in joint replacement use among older adults

BACKGROUND: Although joint replacement can restore function for arthritis patients with severe joint disease, this procedure has not been used equally across racial groups. Differences in joint replacement use are assessed from a national sample. OBJECTIVE: This study evaluates the role of health conditions and economic access to explain differences in joint replacement among older black and Hispanic minorities relative to white persons. DESIGN: Longitudinal (1993-1995) Asset and Health Dynamics Among the Oldest Old (AHEAD) study. SETTING: National probability sample of US community-dwelling older adults. PATIENT POPULATION: AHEAD participants (n = 6159) aged 69 to 103 years. MEASUREMENTS: The outcome is subject-reported 2-year use of any arthritis-related joint-replacement. Independent variables are demographics, health needs (arthritis, other medical conditions, functional health), and economic access (income, assets, education, and health insurance). RESULTS: Older minorities reported arthritis-related joint replacements (black: 0.98%; Hispanic: 0.97%, annually) less frequently compared with white persons (1.48% annually). Older minorities were significantly less likely to use joint replacement compared with white persons (OR, 0.37; 95% CI, 0.20, 0.71) controlling for demographics, and arthritis and other health needs. Disparities remained significant (OR, 0.46; 95% CI, 0.22, 0.98) after additionally controlling for economic medical access. Use was lower among people who depended solely on Medicare compared with those with supplemental health insurance (OR, 0.46; 95% CI, 0.22, 0.95). CONCLUSIONS: These national data document low rates of arthritis-related joint replacement among older Hispanic persons comparable to black persons. Less use among older minorities compared with white persons is not explained by differences in health needs or economic access. Other cultural and attitudinal factors merit investigation to explain disparities.     

Diagnosis of advanced cancer among elderly Medicare and Medicaid patients

BACKGROUND: Medicaid is implicated in late-stage cancer diagnoses, which is the primary indicator of a poor prognosis. OBJECTIVE: We examined Medicaid enrollment and cancer diagnosis in patients ages 66 years and older. Medicaid enrollment was defined as enrolled 12+ months before diagnosis, enrolled <12 months before diagnosis, and enrolled after diagnosis. SUBJECTS: Medicaid and Medicare administrative data were merged with the Michigan Tumor Registry to extract a sample of 46,109 patients with a first primary diagnosis of prostate, lung, breast, or colorectal cancer between 1997 and 2000. Measures were: (1) diagnosed during the same month as death; (2) invasive, but unknown stage; and (3) regional or distant stage disease. RESULTS:: Patients enrolled in Medicaid <12 months before diagnosis were at greater risk of breast (odds ratio [OR] = 2.70; 95% confidence interval [95% CI] = 1.22-5.99) and lung (OR = 2.18; 95% CI = 1.45-3.29) cancer diagnosis in the month of death than Medicare only patients. Similarly, patients with a history of Medicaid enrollment had a high risk of diagnosis with invasive, but unknown breast, lung, and prostate cancer stage. Patients enrolled in Medicaid following diagnosis had a higher risk of late stage colorectal (OR = 1.30; 95% CI = 1.01-1.67), breast (OR = 2.12; 95% CI = 1.60-2.82), and lung (OR = 1.33; 95% CI = 1.02-1.75) cancer relative to Medicare only patients. CONCLUSIONS: There is a preponderance of cancer diagnosis at death and cancer diagnosis with invasive but unknown stage in the Medicaid population, but the appropriateness of these diagnoses is unclear. Late-stage cancer tends to precipitate Medicaid enrollment.     

Racial and ethnic disparities in emergency department–initiated buprenorphine across five health care systems

Background

Opioid overdose deaths have disproportionately impacted Black and Hispanic populations, in part due to disparities in treatment access. Emergency departments (EDs) serve as a resource for patients with opioid use disorder (OUD), many of whom have difficulty accessing outpatient addiction programs. However, inequities in ED treatment for OUD remain poorly understood.

Methods

This secondary analysis examined racial and ethnic differences in buprenorphine access using data from EMBED, a study of 21 EDs across five health care systems evaluating a clinical decision support system for initiating ED buprenorphine. The primary outcome was receipt of buprenorphine, ED administered or prescribed. Hospital type (academic vs. community) was evaluated as an effect modifier. Hierarchical models with cluster effects for site and clinician were used to assess buprenorphine receipt by race and ethnicity.

Results

Black patients were less likely to receive buprenorphine (6.4% [51/801] vs. White patients 8.5% [268/3154], odds ratio [OR] 0.59, 95% confidence interval [CI] 0.45–0.78). This association persisted after adjusting for age, insurance, gender, clinician X-waiver, hospital type, and urbanicity (adjusted OR [aOR] 0.64, 95% CI 0.48–0.84) but not when discharge diagnosis was included (aOR 0.75, 95% CI 0.56–1.02). Hispanic patients were more likely to receive buprenorphine (14.8% [122/822] vs. non-Hispanic patients, 11.6% [475/4098]) in unadjusted (OR 1.57, 95% CI 1.09–1.83) and adjusted models (aOR 1.41, 95% CI 1.08–1.83) but not including discharge diagnosis (aOR 1.32, 95% CI 0.99–1.77). Odds of buprenorphine were similar in academic and community EDs by race (interaction p = 0.97) and ethnicity (interaction p = 0.64).

Conclusions

Black patients with OUD were less likely to receive buprenorphine whereas Hispanic patients were more likely to receive buprenorphine in academic and community EDs. Differences were attenuated with discharge diagnosis, as fewer Black and non-Hispanic patients were diagnosed with opioid withdrawal. Barriers to medication treatment are heterogenous among patients with OUD; research must continue to address the multiple drivers of health inequities at the patient, clinician, and community level.     

Insurance Status and the Treatment of Myocardial Infarction at Academic Centers

Numerous studies have documented treatment disparities in patients with acute coronary syndromes based on race and gender. Other causes for treatment disparities may exist. OBJECTIVES: To determine if insurance status affects quality of care in patients with acute myocardial infarction (AMI) presenting to academic health centers. METHODS: The Internet Tracking Registry for Acute Coronary Syndromes (i*trACS), a prospective multicenter registry of patients with chest pain presenting to the emergency department who receive an electrocardiogram, was used as the database (N = 17,737). A subset of patients who were diagnosed as having AMI were selected from the database (n = 936). Patients were classified as having either ST-segment elevation MI (n = 178) or non-ST-segment elevation MI (n = 758). Insurance status, age, race, and gender were extracted as predictor variables. The influence of predictor variables on treatment modality was investigated using logistic regression, adjusted for clustering within sites. RESULTS: The odds of a self-pay patient with ST-segment elevation MI receiving fibrinolytics were 3.23 (95% CI = 1.56 to 6.69) times higher than for other patients. Patients with Medicare coverage were less likely to receive fibrinolytics (odds ratio [OR] 0.35, 95% CI = 0.19 to 0.65) and tended to undergo percutaneous coronary intervention less often (OR 0.60, 95% CI = 0.36 to 1.01). The odds of a privately insured patient's receiving coronary artery bypass grafting (OR 2.76, 95% CI = 1.62 to 4.72) or percutaneous coronary intervention (OR 1.47, 95% CI = 1.03 to 2.11) were higher than for other patients. CONCLUSIONS: Insurance coverage appears to affect treatment in patients with AMI, with self-pay patients more likely to receive less-expensive therapies and insured patients more likely to receive invasive treatments.     

Disparities in health care by race, ethnicity, and language among the insured: findings from a national sample.

BACKGROUND: Racial and ethnic disparities in health care have been well documented, but poorly explained. OBJECTIVE: To examine the effect of access barriers, including English fluency, on racial and ethnic disparities in health care. RESEARCH DESIGN: Cross-sectional analysis of the Community Tracking Survey (1996-1997). SUBJECTS: Adults 18 to 64 years with private or Medicaid health insurance. MEASURES: Independent variables included race, ethnicity, and English fluency. Dependent variables included having had a physician or mental health visit, influenza vaccination, or mammogram during the past year. RESULTS: The health care use pattern for English-speaking Hispanic patients was not significantly different than for non-Hispanic white patients in the crude or multivariate models. In contrast, Spanish-speaking Hispanic patients were significantly less likely than non-Hispanic white patients to have had a physician visit (RR, 0.77; 95% CI, 0.72-0.83), mental health visit (RR, 0.50; 95% CI, 0.32-0.76), or influenza vaccination (RR, 0.30; 95% CI, 0.15-0.52). After adjustment for predisposing, need, and enabling factors, Spanish-speaking Hispanic patients showed significantly lower use than non-Hispanic white patients across all four measures. Black patients had a significantly lower crude relative risk of having received an influenza vaccination (RR, 0.73; 95% CI, 0.58-0.87). Adjustment for additional factors had little impact on this effect, but resulted in black patients being significantly less likely than non-Hispanic white patients to have had a visit with a mental health professional (RR, 0.46; 95% CI, 0.37-0.55). CONCLUSIONS: Among insured nonelderly adults, there are appreciable disparities in health-care use by race and Hispanic ethnicity. Ethnic disparities in care are largely explained by differences in English fluency, but racial disparities in care are not explained by commonly used access factors.     

Medicaid expansion and resource utilization in the emergency department

BackgroundThe Affordable Care Act (ACA) has impacted the insurance mix of emergency department (ED) visits, yet the degree to which this has influenced provider behavior is not clear.MethodsThis was a difference-in-differences (DID) analysis of ED-visit data from five states in 2013 and 2014. Sample states included 3 expanding Medicaid under the ACA, 1 rejecting ACA funding and delaying an eligibility expansion, and 1 with no eligibility change. We included self-pay and Medicaid patients aged 27 to 64 years. A subsample analysis was done for chest pain visits. DID logistic models were estimated for likelihood of admission for given Medicaid-paid ED visits in expansion states as compared to non-expansion states. Among chest pain visits we assessed likelihood given visits resulted in admission or advanced cardiac imaging, where clinician discretion may be more significant.ResultsA total of 8,157,748 ED visits with primary payer Medicaid and self-pay were included, of which 331,422 were for chest pain. The proportion of visits paid for by Medicaid rose in expansion states by between 15.8% and 38.9%. Medicaid eligibility expansion was associated with increased odds of admission (OR 1.070 [95% CI 1.051–1.089]). Among chest pain visits, expansion was associated with increased odds of admission (OR 1.294 [95% CI 1.144–1.464]), but not advanced cardiac imaging (OR 1.099 [95% CI 0.983–1.229]).ConclusionMedicaid expansion was associated with small increases in ED visit admissions across the board and among the subgroup of patients presenting with chest pain.     

Exploring the determinants of racial and ethnic disparities in total knee arthroplasty: health insurance, income, and assets

OBJECTIVE: To estimate national total knee arthroplasty (TKA) rates by economic factors, and the extent to which differences in insurance coverage, income, and assets contribute to racial and ethnic disparities in TKA use. DATA SOURCE: US longitudinal Health and Retirement Study survey data for the elderly and near-elderly (biennial rounds 1994-2004) from the Institute of Social Research, University of Michigan. STUDY DESIGN: The outcome is dichotomous, whether the respondent received first TKA in the previous 2 years. Longitudinal, random-effects logistic regression models are used to assess associations with lagged economic indicators. SAMPLE: Sample was 55,469 person-year observations from 18,439 persons; 663, with first TKA. RESULTS: Racial/ethnic disparities in TKA were more prominent among men than women. For example, relative to white women, odds ratios (ORs) were 0.94, 0.46, and 0.79, for white, black, and Hispanic men, respectively (P < 0.05 for black men). After adjusting for economic factors, racial/ethnic differences in TKA rates for women essentially disappeared, while the deficit for black men remained large. Among Medicare-enrolled elderly, those with supplemental insurance may be more likely to have first TKA compared with those without it, whether the supplemental coverage was private [OR: 1.27; 95% confidence interval (CI): 0.82-1.96] or Medicaid (OR: 1.18; 95% CI: 0.93-1.49). Among the near-elderly (age 47-64), compared with the privately insured, the uninsured were less likely (OR: 0.61; 95% CI: 0.40-0.92) and those with Medicaid more likely (OR: 1.53; 95% CI: 1.03-2.26) to have first TKA. CONCLUSIONS: Limited insurance coverage and financial constraints explain some of the racial/ethnic disparities in TKA rates.     

Emergency department patient payer status after implementation of the Affordable Care Act: A nationwide analysis using NHAMCS data

ObjectiveTo evaluate changes in insurance status among emergency department (ED) patients presenting in the two years immediately before and after full implementation of the Affordable Care Act (ACA).MethodsWe evaluated National Hospital Ambulatory Medical Care Survey (NHAMCS) Emergency Department public use data for 2012–2015, categorizing patients as having any insurance (private; Medicare; Medicaid; workers' compensation) or no insurance. We compared the pre- and post-ACA frequency of insurance coverage—overall and within the older (≥65), working-age (18–64) and pediatric (<18) subpopulations—using unadjusted odds ratios with 95% confidence intervals. We also conducted a difference-in-differences analysis comparing the change in insurance coverage among working-age patients with that observed for older Medicare-eligible patients, while controlling for sex, race and underlying temporal trends.ResultsOverall, the proportion of ED patients with any insurance did not significantly change from 2012 to 2013 to 2014–2015 (74.2% vs 77.7%) but the proportion of working-age adult patients with at least one form of insurance increased significantly, from 66.0% to 71.8% (OR 1.31, CI: 1.13–1.52). The difference-in-differences analysis confirmed the change in insurance coverage among working-age adults was greater than that seen in the reference population of Medicare-eligible adults (AOR 1.70, CI: 1.29–2.23). The increase was almost entirely attributable to increased Medicaid coverage.ConclusionIn the first two years following full implementation of the ACA, there was a significant increase in the proportion of working-age adult ED patients who had at least one form of health insurance. The increase appeared primarily associated with expansion of Medicaid.     

Ethnic differences in antihypertensive medication use in the elderly

BACKGROUND: Determining the optimal treatment for hypertension in very old patients requires better understanding of interethnic differences in patterns and predictors of antihypertensive drug use in this population. OBJECTIVE: To investigate interethnic variations in antihypertensive drug use in a tri-ethnic sample of community-dwelling adults aged > or =77 years. METHODS: We performed a cross-sectional study of non-Hispanic white, black, and Hispanic adults > or =77 years old residing in Galveston County, TX. In-home interviews in 1997 and 1998 assessed blood pressures and antihypertensive medication use in 281 subjects who reported having hypertension or who had a systolic blood pressure > or =140 mm Hg and/or diastolic blood pressure > or =90 mm Hg. RESULTS: Of the population evaluated, 62.9% of non-Hispanic whites, 60.2% of blacks, and 45.2% of Hispanics with hypertension were on antihypertensive medications (p < 0.027 across the ethnic groups). After adjusting for age, gender, years of education, household income, Medicaid insurance, number of physician visits, and cognitive function, Hispanic ethnicity, unlike black ethnicity, continued to be significantly associated with lower use of antihypertensive drugs compared with non-Hispanic whites (OR 0.41; 95% CI 0.19 to 0.90). Characteristics associated with the lower use of antihypertensive drugs included older age and low income in whites, poor cognition and infrequent physician visits in blacks, and lack of Medicaid insurance in Hispanics. CONCLUSIONS: In the elderly, Hispanic ethnicity, unlike black ethnicity, is significantly associated with lower use of antihypertensive drug therapy compared with non-Hispanic white ethnicity, adjusting for relevant sociodemographic and health factors.     

Preventive services among Medicare beneficiaries with supplemental coverage versus HMO enrollees, medicaid recipients, and elders with no additional coverage

BACKGROUND: Studies conducted when Medicare began to cover preventive services, found that beneficiaries with supplemental insurance were much more likely to have such services than those without additional coverage. OBJECTIVE: To examine preventive services among Medicare beneficiaries with supplemental insurance, Medicaid, health maintenance organization (HMO) enrollees, and those without additional insurance. RESEARCH DESIGN: Analysis of the 1996 Medical Expenditure Panel Survey, a nationally representative multistage survey. SUBJECTS: 2,251 persons aged 65 and older with Medicare coverage. MEASURES: Self-reported preventive services, specifically, blood pressure measurement, cholesterol testing, influenza vaccination, mammography, Papanicolau (Pap) testing, and breast and prostate examinations. Multivariate modeling was used to adjust for age, education, race/ethnicity, and functional status. RESULTS: Elders without additional coverage were approximately 10% points less likely to have influenza vaccination, cholesterol testing, mammography, or Pap smears than those with supplemental coverage (P < 0.05). Multivariate adjustment attenuated some of these differences with age and education being the most important predictors of having preventive services. HMO enrollees were more likely to have mammograms than those with supplemental coverage (P < 0.05). CONCLUSIONS: Several years after Medicare extended coverage to include preventive services, differences in utilization of such services among elders with and without supplemental insurance have narrowed substantially.     

Relation of gender and health insurance to cardiovascular procedure use in persons with progression of chronic renal disease

BACKGROUND: Women often are less likely than men to receive diagnostic and therapeutic invasive procedures for coronary disease. OBJECTIVE: To examine the relation between gender, health insurance, and access to cardiovascular procedures over time in persons with chronic illness. RESEARCH DESIGN: Seven-year longitudinal analyses in a cohort from the United States Renal Data System. SUBJECTS: National random sample of women and men who progressed to end-stage renal disease (ESRD) in 1986 to 1987 and were treated at 303 dialysis facilities (n = 4,987). MEASURES: Medical history and utilization records, physical examination, and laboratory data. MAIN OUTCOME MEASURES: Receipt of a coronary catheterization or revascularization procedure before (baseline) and after (follow-up) the development of ESRD and acquisition of Medicare, adjusted for clinical and socioeconomic variables. RESULTS: At baseline, 5.2% of women and 9.2% of men had undergone a cardiac procedure; the odds of women receiving a procedure were one third lower than for men (adjusted odds ratio 0.66 [95% CI 0.49-0.88]). During follow-up, women were just as likely as men to undergo a procedure (adjusted odds ratio 0.94 [95% CI 0.74-1.20]). Compared with men with baseline private insurance, men and women with other and no insurance had 34% to 81% lower odds of receiving procedures at baseline. Women with private insurance had 42% lower odds of having a procedure at baseline compared with men (adjusted odds ratio 0.58 [95% CI 0.42-0.78]) but had the same odds at follow-up (adjusted odds ratio 1.09 [95% CI 0.82-1.45]). At follow-up, gender differences in procedure use were eliminated for groups with baseline Medicaid or no insurance. CONCLUSIONS: Overall gender differences in cardiac procedure use were narrowed markedly after progression of a serious illness, the assurance of health insurance, and entry into a comprehensive care system. Gender disparities in procedure use for different baseline insurance groups were largely equalized in follow-up. These findings suggest that provision of insurance with disease-managed care for a chronic disease can provide equalized access to care for women.     

“I'm Leaving”: Factors That Impact Against Medical Advice Disposition Post-Trauma

BackgroundDischarge against medical advice (AMA) is an important, yet understudied, aspect of health care—particularly in trauma populations. AMA discharges result in increased mortality, increased readmission rates, and higher health care costs.ObjectiveThe goal of this analysis was to determine what factors impact a patient's odds of leaving the hospital prior to treatment.MethodsWe performed a retrospective analysis of the National Trauma Data Bank on adult trauma patients (older than 14 years) from 2013 to 2015. Of the 1,770,570 patients with known disposition, excluding mortality, 24,191 patients (1.4%) left AMA. We ascertained patient characteristics including age, sex, race, ethnicity, insurance status, ETOH, drug use, geographic location, Injury Severity Score (ISS), injury mechanism, and anatomic injury location. Multivariate logistic regression models were used to determine which patient factors were associated with AMA status.ResultsUninsured (odds ratio [OR] 2.72; 95% confidence interval [CI] 2.58–2.86) or Medicaid-insured (OR 2.50; 95% CI 2.37–2.63) trauma patients were significantly more likely to leave AMA than patients with private insurance. Compared to white patients, African-American patients (OR 1.06; 95% CI 1.02–1.11) were more likely, and Native-American (OR 0.62; 95% CI 0.52–0.75), Asian (OR 0.59; 95% CI 0.49–0.69), and Hispanic (OR 0.80; 95% CI 0.75–0.85) patients were less likely, to leave AMA when controlling for age, sex, ISS, and type of injury.ConclusionsInsurance status, race, and ethnicity are associated with a patient's decision to leave AMA. Uninsured and Medicaid patients have more than twice the odds of leaving AMA. These findings demonstrate that racial and socioeconomic disparities are important targets for future efforts to reduce AMA rates and improve outcomes from blunt and penetrating trauma.     

The acceptability of treatment for depression among African-American,Hispanic, and white primary care patients

BACKGROUND: Ethnic minority patients are less likely than white patients to receive guideline-concordant care for depression. It is uncertain whether racial and ethnic differences exist in patient beliefs, attitudes, and preferences for treatment. METHODS: A telephone survey was conducted of 829 adult patients (659 non-Hispanic whites, 97 African Americans, 73 Hispanics) recruited from primary care offices across the United States who reported 1 week or more of depressed mood or loss of interest within the past month and who met criteria for Major Depressive Episode in the past year. Within this cohort, we examined differences among African Americans, Hispanics, and whites in acceptability of antidepressant medication and acceptability of individual counseling. RESULTS: African Americans (adjusted OR, 0.30; 95% CI 0.19-0.48) and Hispanics (adjusted OR, 0.44; 95% CI, 0.26-0.76) had lower odds than white persons of finding antidepressant medications acceptable. African Americans had somewhat lower odds (adjusted OR, 0.63; 95% CI, 0.35-1.12), and Hispanics had higher odds (adjusted OR, 3.26; 95% CI, 1.08-9.89) of finding counseling acceptable than white persons. Some negative beliefs regarding treatment were more prevalent among ethnic minorities; however adjustment for these beliefs did not explain differences in acceptability of treatment for depression. CONCLUSIONS: African Americans are less likely than white persons to find antidepressant medication acceptable. Hispanics are less likely to find antidepressant medication acceptable, and more likely to find counseling acceptable than white persons. Racial and ethnic differences in beliefs about treatment modalities were found, but did not explain differences in the acceptability of depression treatment. Clinicians should consider patients' cultural and social context when negotiating treatment decisions for depression. Future research should identify other attitudinal barriers to depression care among ethnic minority patients.     

Seizure visits in US emergency departments: epidemiology and potential disparities in care

Introduction

While epilepsy is a well-characterized disease, the majority of emergency department (ED) visits for “seizure” involve patients without known epilepsy. The epidemiology of seizure presentations and national patterns of management are unclear. The aim of this investigation was to characterize ED visits for seizure in a large representative US sample and investigate any potential impact of race or ethnicity on management.

Methods

Seizure visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1993 to 2003 were analysed. Demographic factors associated with presentation, neuroimaging and hospital admission in the USA were analysed using controlled multivariate logistic regression.

Results

Seizure accounts for 1 million ED visits annually [95% confidence interval (CI): 926,000–1,040,000], or 1% of all ED visits in the USA. Visits were most common among infants, at 8.0 per 1,000 population (95% CI: 6.0–10.0), and children aged 1–5 years (7.4; 95% CI: 6.4–8.4). Seizure was more likely among those with alcohol-related visits [odds ratio (OR): 3.2; 95% CI: 2.7–3.9], males (OR: 1.4; 95% CI: 1.3–1.5) and Blacks (OR: 1.4; 95% CI: 1.3–1.6). Neuroimaging was used less in Blacks than Whites (OR: 0.6; 95% CI: 0.4–0.8) and less in Hispanics than non-Hispanics (OR: 0.6; 95% CI: 0.4–0.9). Neuroimaging was used less among patients with Medicare (OR: 0.4; 95% CI: 0.2–0.6) or Medicaid (OR: 0.5; 95% CI: 0.4–0.7) vs private insurance and less in proprietary hospitals. Hospital admission was less likely for Blacks vs Whites (OR: 0.6; 95% CI: 0.4–0.8).

Conclusion

Seizures account for 1% of ED visits (1 million annually). Seizure accounts for higher proportions of ED visits among infants and toddlers, males and Blacks. Racial/ethnic disparities in neuroimaging and hospital admission merit further investigation.