Methods for using Medicare data to compare procedure rates among Asians, blacks, Hispanics, Native Americans, and whites

OBJECTIVE: Small sample sizes in Asian, Hispanic, and Native American groups and misreporting of race/ethnicity across all groups (including blacks and whites) limit the usefulness of racial/ethnic comparisons based on Medicare data. The objective of this paper is to compare procedure rates for these groups using Medicare data, to assess how small sample size and misreporting affect the validity of comparisons, and to compare rates after correcting for misreporting. DATA: We use 1997 physician claims data for a 5 percent sample of Medicare beneficiaries aged 65 and older to study cardiac procedures and tests. STUDY DESIGN: We calculate age and sex-adjusted rates and confidence intervals by race/ethnicity. Confidence intervals are compared among the groups. Out-of-sample data on misreporting of race/ethnicity are used to assess potential bias due to misreporting, and to correct for the bias. PRINCIPAL FINDINGS: Sample sizes are sufficient to find significant ethnic and racial differences for most procedures studied. Blacks' rates tend to be lower than whites. Asian and Hispanic rates also tend to be lower than whites', and about the same as blacks'. Sample sizes for Native Americans are very small (about .1 percent of the data); nonetheless, some significant differences from whites can still be identified. Biases in rates due to misreporting are small (less than 10 percent) for blacks, Hispanics, and whites. Biases in rates for Asians and Native Americans are greater, and exceed 20 percent for some procedures. CONCLUSIONS: Sample sizes for Asians, blacks, and Hispanics are generally adequate to permit meaningful comparisons with whites. Implementing a correction for misreporting makes Medicare data useful for all ethnic groups. Misreporting race/ethnicity and small sample sizes do not materially limit the usefulness of Medicare data for comparing rates among racial and ethnic groups.     

Parents' perceptions of pediatric primary care quality: effects of race/ethnicity,language, and access

OBJECTIVE: To examine the effects of race/ethnicity, language, and potential access on parents' reports of pediatric primary care experiences. DATA SOURCES/STUDY SETTING: Primary survey data were collected (67 percent response rate) from 3,406 parents of students in kindergarten through sixth grade in a large urban school district in California during the 1999-2000 school year. DATA COLLECTION: The data were collected by mail, telephone, and in person. Surveys were administered in English, Spanish, Vietnamese, and Tagalog. STUDY DESIGN: Data were analyzed using multiple regression models. The dependent variable was parents' reports of primary care quality, assessed via the previously validated Parents' Perceptions of Primary Care measure (P3C). The independent variables were race/ethnicity, language, and potential access to care (insurance status, presence of a regular provider of care), controlling for child age, gender, and chronic health condition status, and mother's education. PRINCIPAL FINDINGS: Parents' reports of primary care quality varied according to race/ethnicity, with Asian and Latino parents reporting lower P3C scores than African Americans and whites. In multivariate analyses, both language and potential access exerted strong independent effects on primary care quality, reducing the effect of race/ethnicity such that the coefficient for Latinos was no longer significant, and the coefficient for Asians was much smaller, though still statistically significant. CONCLUSIONS: To reduce racial/ethnic disparities in primary care, attention should be paid both to policies aimed at improving potential access and to providing linguistically appropriate services.     

Smoking during pregnancy among northwest Native Americans.

There is little available information on the smoking habits of Native Americans. The authors used data from the Washington State birth certificate to determine the prevalence of smoking during pregnancy among Native American mothers in Washington State. From 1984 through 1988, 39.8 percent of all Native Americans smoked during their pregnancy. Smoking patterns during pregnancy differed markedly between Native Americans and whites according to maternal age and marital status. The smoking prevalence in Native Americans, adjusted for maternal age and marital status, was 1.3 times higher than that found in Washington State white women. This is the first analysis of statewide smoking rates during pregnancy among Native Americans. The birth certificate can serve as a readily accessible and low cost surveillance system for populations such as Native Americans, who are otherwise difficult to study. Smoking intervention programs need to be targeted at Native Americans, and how their smoking patterns differ from those of the general population needs to be recognized.     

Do biological,sociodemographic, and behavioral characteristics explain racial/ethnic disparities in preterm births?

Many studies find racial/ethnic disparities in a diverse set of birth outcomes. However few empirical studies have examined the existence and possible explanations for racial/ethnic disparities in preterm births using a diverse set of racial/ethnic categories and a nationally representative sample of births. This research fills that gap. Using data from the US Early Childhood Longitudinal Study – Birth Cohort (ECLS-B), this research first explores the distribution of biological, sociodemographic, and behavioral characteristics of mothers and infants based on seven categories of maternal race/ethnicity. Next, multivariable logistic regression models are estimated in a nested manner to test for possible explanations for racial/ethnic disparities in preterm births. Lastly, race-stratified models are estimated to better elucidate the mechanism leading to racial/ethnic disparities in preterm births. Results from the chi-square tests of significance for racial/ethnic differences indicate that all variables used in this analysis, except for infant's gender, differ significantly based on maternal race/ethnicity. Results from the full multivariable logistic regression model finds that the only racial/ethnic disparity found in preterm births is observed for infants born to Native American mothers compared to non-Hispanic white mothers, once all variables are controlled for in the model. Race-stratified models indicate that maternal health complications and prenatal care adequacy offer the most potential in explaining remaining racial/ethnic disparities in preterm births. Results from this research support the need to increase access to appropriate and timely prenatal care for women of all races/ethnicities in an effort to reduce racial/ethnic disparities in preterm births.     

Socioeconomic and Racial/Ethnic Disparities in Unintended Pregnancy Among Postpartum Women in California

Objective: We examined social disparities in unintended pregnancy among postpartum women to better understand 1) the role of socioeconomic factors in racial/ethnic disparities and 2) factors that might explain both socioeconomic and racial/ethnic disparities in the risk for unintended pregnancy among women who give birth. Methods: We used 1999 and 2000 data from a statewide-representative mail and telephone survey of postpartum women in California (N = 7044). We examined associations between unintended pregnancy and race/ethnicity (African American, Asian or Pacific Islander, U.S.-born Latina, foreign-born Latina, European or Middle Eastern), three socioeconomic factors (poverty status, maternal education, paternal education), and several potential explanatory factors. Results: Overall, racial/ethnic disparities in unintended pregnancy were reduced by the three socioeconomic factors individually and collectively (e.g., reducing higher unadjusted odds for African Americans from 3.4 to 1.9); additional adjustment for marital status age, parity, insurance, language, abuse, sense of control, and interaction between marital status and race/ethnicity (each independently associated with unintended pregnancy) reduced the socioeconomic disparities (e.g., reducing odds for the poorest women from 4.1 to 2.3). Although reduced, significant racial/ethnic and socioeconomic disparities remained after adjustment, but generally only among married women. Results for Latinas appeared to vary by nativity, with foreign-born Latinas being at lower odds and U.S.-born Latinas being at higher odds of unintended pregnancy. Conclusions: Racial/ethnic disparities in unintended pregnancy are partly explained by the socioeconomic factors we measured. Several additional factors were identified that suggest possible directions for policies and programs to help reduce social disparities in unintended pregnancy among childbearing women.     

Racial and Ethnic Disparities and Perceptions of Health Care: Does Health Plan Type Matter?

OBJECTIVE: To examine whether racial and ethnic differences in the distribution of individuals across types of health plans explain differences in satisfaction and trust with their physicians. DATA SOURCES: Data were derived from the 1998-1999 Community Tracking Household and Followback Studies and consisted of a nationwide sample of adults (18 years and older). DATA COLLECTION: The data were collected by telephone survey. Surveys were administered in English and Spanish. The response rate for the Household Survey was 63 percent, and the match rate for the Followback Survey was 59 percent. STUDY DESIGN: Multivariate analyses used regression methods to detect independent effects of respondent race and ethnicity on satisfaction and trust with physician, while controlling for enrollment in different types of health plans. PRINCIPAL FINDINGS: Racial and ethnic minorities are more likely than whites to have lower levels of trust and satisfaction with their physician. The most prominent differences occurred within the Latino and Native American/Asian American/Pacific Islander/Other ("Other") populations. Plan type does not mitigate the relationship between race/ethnicity and trust and satisfaction for the overall adult population. CONCLUSIONS: Disparate levels of trust and satisfaction exist within ethnic and minority populations, even when controlling for the distribution of individuals across types of health plans. The results demonstrate a need to better understand the health care-related factors that drive disparate trust and satisfaction.     

1994–1996 U.S. Singleton Birth Weight Percentiles for Gestational Age by Race,Hispanic Origin,and Gender

Objectives: Establishing and comparing race, ethnic, and gender-specific birth weight percentiles for gestational age is requisite for investigating the determinants of variations in fetal growth. In this study, we calculate percentiles of birth weight for gestational age for the total 1994–1996 U.S. population and contrast these percentiles by racial/ethnic and gender groups. Methods: Single live births to U.S. resident mothers were selected from the 1994–1996 U.S. Natality Files. After exclusions, 5,973,440 non-Hispanic Whites, 1,393,908 non-Hispanic African Americans, 1,683,333 Hispanics, 80,187 Native Americans, and 510,021 other racial/ethnic groups were used to calculate distribution percentiles of birth weight for each gestational age for which there were at least 50 cases to calculate the 50th percentile and 100 cases to calculate the 10th percentile. Results: Fetal growth patterns among the four U.S. racial/ethnic groups varied markedly and, across the gestational age range, there was considerable oscillation in the relative ranking of any one group's birth weight percentile value in comparison to the others. Males had relatively higher birth weight percentile values than females. The proportion of infants with a birth weight value less than 1994–1996 U.S. population's 10th percentile value of birth weight for their corresponding gestational age was 7.87 for non-Hispanic Whites, 15.43 for non-Hispanic African Americans, 9.30 for Hispanics, and 8.81 for Native Americans. Conclusions: While the factors underlying trends and population subgroup differences in fetal growth are unclear, nutrition, smoking habits, health status, and maternal morbidity are possible precursors for part of the variations in patterns of fetal growth. As prenatal care has been touted as a means to reduce the risk of fetal growth restriction at term, assuring the availability and accessibility of comprehensive prenatal care services is viewed as an essential corollary in the effort to improve fetal growth patterns in the United States.     

Effect of “This Side Up” T-shirts on Infant Sleep Position

Objectives: To assess the impact of “This Side Up” T-shirts on parental practices in Nebraska. Methods: A random sample of 3,210 Nebraska women who gave birth in 2004, stratified by race/ethnicity, was mailed a brief questionnaire on their receipt of a T-shirt and SIDS risk reduction materials at their birthing hospital, and on infant sleep position. Results: Response rates were low (25.9%), ranging from 10.6% for Native American mothers to 46.4% for White mothers. Half (52.0%) had received a T-shirt and 71.6% had received SIDS information. Two-thirds (64.0%) reported that their infants slept on their backs; African-American and Hispanic infants were significantly less likely to back sleep. In univariate logistic regression models, African-American race, Hispanic ethnicity and maternal age 30–39 were significant negative predictors of back sleeping; White race and having received a SIDS brochure were positive predictors. In the fully controlled model African American and Asian race and Hispanic ethnicity were negative predictors of back sleeping; neither receiving SIDS information nor the infant T-shirt was significant. Effects of maternal age and a SIDS informational brochure appeared in models stratified by race/ethnicity. Conclusions: In these data, receiving an infant T-shirt was not related to how mothers placed their infants to sleep. Additional research is needed on effective methods of delivering targeted counseling and promoting safe sleep practices among families, particularly among racial and ethnic subgroups.     

One Size Does Not Fit All: An Examination of Low Birthweight Disparities Among a Diverse Set of Racial/Ethnic Groups

To examine disparities in low birthweight using a diverse set of racial/ethnic categories and a nationally representative sample. This research explored the degree to which sociodemographic characteristics, health care access, maternal health status, and health behaviors influence birthweight disparities among seven racial/ethnic groups. Binary logistic regression models were estimated using a nationally representative sample of singleton, normal for gestational age births from 2001 using the ECLS-B, which has an approximate sample size of 7,800 infants. The multiple variable models examine disparities in low birthweight (LBW) for seven racial/ethnic groups, including non-Hispanic white, non-Hispanic black, U.S.-born Mexican-origin Hispanic, foreign-born Mexican-origin Hispanic, other Hispanic, Native American, and Asian mothers. Race-stratified logistic regression models were also examined. In the full sample models, only non-Hispanic black mothers have a LBW disadvantage compared to non-Hispanic white mothers. Maternal WIC usage was protective against LBW in the full models. No prenatal care and adequate plus prenatal care increase the odds of LBW. In the race-stratified models, prenatal care adequacy and high maternal health risks are the only variables that influence LBW for all racial/ethnic groups. The race-stratified models highlight the different mechanism important across the racial/ethnic groups in determining LBW. Differences in the distribution of maternal sociodemographic, health care access, health status, and behavior characteristics by race/ethnicity demonstrate that a single empirical framework may distort associations with LBW for certain racial and ethnic groups. More attention must be given to the specific mechanisms linking maternal risk factors to poor birth outcomes for specific racial/ethnic groups.     

Elevated birth defects in racial or ethnic minority children of women living near hazardous waste sites

This case-control study evaluated the relationship between birth defects in racial or ethnic minority children born during 1983-1988 and the potential exposure of their mothers to contaminants at hazardous waste sites in California. Four categories of race or ethnicity were used: black/African American, Hispanic/Latino, American Indian/Alaska Native, and Asian/Pacific Islander. Case subjects were 13,938 minority infants with major structural birth defects (identified by the California Birth Defects Monitoring Program) whose mothers resided in selected counties at the time of delivery. The control group was composed of 14,463 minority infants without birth defects who were randomly selected from the same birth cohort as the case subjects. The potential for exposure was determined by whether the mother resided at the time of delivery in the same census tract as a hazardous waste site that was on the U.S. Environmental Protection Agency's National Priorities List (NPL). Racial/ethnic minority infants whose mothers had been potentially exposed to hazardous waste were at slightly increased risk for birth defects (odds ratio [OR] = 1.12, 95% confidence interval [CI] = 0.98-1.27) than were racial/ethnic minority infants whose mothers had not been potentially exposed. The greatest association was between potential exposure and neural tube defects (OR = 1.54, 95% CI = 0.93-2.55), particularly anencephaly (OR = 1.85, 95% CI = 0.91-3.75). The strongest association between birth defects and potential exposure was among American Indians/Alaska Natives (OR = 1.19, 95% CI = 0.62-2.27). Despite the limitations of this study, the consistency of these findings with previous studies suggests an association between environmental risk factors and birth defects. This is particularly relevant to minority populations. We recommend further investigation of birth defects among minority communities, particularly among American Indians/Alaska Natives. Special attention should also be paid to those defects and contaminants that consistently are associated with exposure to hazardous waste.     

Use of death certificates to study ethnic-specific mortality

OBJECTIVES: The Hispanic population in the United States represents more than 40 million individuals, with Mexican Americans (MA) as the largest subgroup. To assess the utility of death certificates and medical records as the source of race/ethnicity data for epidemiologic studies, we compared self-reported race/ ethnicity to race/ethnicity recorded on death certificates and medical records in a bi-ethnic, non-immigrant U.S. community with a significant MA population. METHODS: This study utilized data collected from a subset of 1,856 participants of the Brain Attack Surveillance in Corpus Christi (BASIC) project. In-person interviews were conducted to determine self-reported race/ethnicity. Of those interviewed, 480 subsequently expired. Using self-reported race/ethnicity as the gold standard, we determined percent agreement, sensitivity, and specificity of the death certificate and medical record. RESULTS: Of the 480 subjects, 259 self-reported their race/ethnicity as non-Hispanic white (NHW), 195 self-reported as MA, and 26 self-reported as non-Hispanic black. Median age was 78.5 years and 55.8% were female. Percent agreement between self-reported race/ethnicity and race/ethnicity recorded on the death certificate and medical record was 97.1% and 96.3% respectively. Five percent of MAs were misclassified as NHW on their death certificates and 3% on their medical records. CONCLUSIONS: Results indicated that Hispanic designation recorded on death certificates and medical records in this community was largely consistent with that of self-report. This study suggests that vital statistics data in non-immigrant U.S. Hispanic communities can be used with confidence to investigate ethnic-specific aspects of disease and mortality. Similar studies in other multi-racial communities should be conducted to confirm and generalize these results.     

Racial and ethnic differences in determinants of intrauterine growth retardation and other compromised birth outcomes.

OBJECTIVES: This study examined the extent of variation by race/ethnicity in the prevalence of adverse birth outcomes, whether differentials persisted after other risk factors were controlled for, and whether the direction and magnitude of relationships differed by type of outcome. METHODS: A revised system of measurement was used to estimate multinomial logistic models in a large, nationally representative US data set. RESULTS: Considerable racial/ethnic variation was found across birth outcome categories; differences persisted in the adjusted parameter estimates; and the effects of other risk factors on birth outcomes were similar as to direction, but varied somewhat in magnitude. The odds of compromised birth outcomes were much higher among African Americans than among Mexican Americans and non-Hispanic Whites. CONCLUSIONS: In addition to persistent racial inequality, we found strong adverse effects of both inadequate and "adequate-plus" prenatal care and smoking. Risk of intrauterine growth retardation was higher in the absence of medical insurance, and risk of all adverse birth outcomes was lower among mothers participating in the Special Supplemental Food Program for Women, Infants, and Children.     

The public health impact of coccidioidomycosis in Arizona and California

The numbers of reported cases of coccidioidomycosis in Arizona and California have risen dramatically over the past decade, with a 97.8% and 91.1% increase in incidence rates from 2001 to 2006 in the two states, respectively. Of those cases with reported race/ethnicity information, Black/African Americans in Arizona and Hispanics and African/Americans in California experienced a disproportionately higher frequency of disease compared to other racial/ethnic groups. Lack of early diagnosis continues to be a problem, particularly in suspect community-acquired pneumonia, underscoring the need for more rapid and sensitive tests. Similarly, the inability of currently available therapeutics to reduce the duration and morbidity of this disease underscores the need for improved therapeutics and a preventive vaccine.     

Systematic review identified suboptimal reporting and use of race/ethnicity in general medical journals

OBJECTIVE: Methods of reporting of race/ethnicity in biomedical journals are largely unknown. We aimed to systematically examine the reporting practice of race/ethnicity and socioeconomic status (SES) information in biomedical journals. STUDY DESIGN AND SETTING: All primary research articles that reported more than one racial/ethnic group, published between 1999 and 2003 in Annals of Internal Medicine, JAMA, The Lancet, and The New England Journal of Medicine (n=1,152) were reviewed for their use of race/ethnicity and SES variables. Interobserver reliability was assessed by independent abstraction of 10% of study sample. RESULTS: There were a total of 116 different terms used to describe various racial/ethnic groups. Assignment of race/ethnicity by self-report was stated in only 13% of papers; 52% of papers identifying race/ethnicity of study participants did not report any SES information. Overall, 16% of articles explicitly stated reasons for collecting information on race/ethnicity. CONCLUSION: Our results suggest that race/ethnicity information was suboptimally reported in general medical journals. Terminology used was highly variable. Method of establishing racial/ethnic categories, rationale for collecting race/ethnicity data, and SES information were underreported.     

The Washington State Intergenerational Study of Birth Outcomes: methodology and some comparisons of maternal birthweight and infant birthweight and gestation in four ethnic groups

A statewide database of vital records and hospital discharge summaries of obstetric and neonatal admissions for Washington State in 1987-95 was linked to the birth certificates of mothers born in the state. A total of 46,000 births to mothers of four racial/ethnic groups were studied: Whites, African-Americans, Native Americans and Hispanics. For all four groups inverse associations were found between maternal birthweight and infant low birthweight and preterm birth. The birthweight distribution of African-American mothers was displaced markedly downwards compared with the Whites; this difference in maternal birthweight is offered as a partial explanation of the greater prevalence of suboptimal pregnancy outcomes in the former. In contrast, the maternal birthweight distributions of Whites, Native Americans and Hispanics are similar; differences in pregnancy outcomes are probably more related to maternal preconceptional and postnatal factors in these groups as well as differences in pregnancy-related factors. Mothers' birthweight may have clinical value in identifying high-risk pregnancies.     

Measuring socioeconomic status/position in studies of racial/ethnic disparities: maternal and infant health

OBJECTIVE: Theoretical and empiric considerations raise concerns about how socioeconomic status/position (abbreviated here as SES) is often measured in health research. The authors aimed to guide the use of two common socioeconomic indicators, education and income, in studies of racial/ethnic disparities in low birthweight, delayed prenatal care, unintended pregnancy, and breastfeeding intention. METHODS: Data from a statewide postpartum survey in California (N = 10,055) were linked to birth certificates. Overall and by race/ethnicity, the authors examined: (a) correlations among several measures of education and income; (b) associations between each SES measure and health indicator; and (c) racial/ethnic disparities in the health indicators "adjusting" for different SES measures. RESULTS: Education-income correlations were moderate and varied by race/ethnicity. Racial/ethnic associations with the health indicators varied by SES measure, how SES was specified, and by health indicator. CONCLUSIONS: Conclusions about the role of race/ethnicity could vary with how SES is measured. Education is not an acceptable proxy for income in studies of ethnically diverse populations of childbearing women. SES measures generally should be outcome- and population-specific, and chosen on explicit conceptual grounds; researchers should test multiple theoretically appropriate measures and consider how conclusions might vary with how SES is measured. Researchers should recognize the difficulty of measuring SES and interpret findings accordingly.     

Discrepancies between published data on racial classification and self-reported race: evidence from the 2002 North Carolina live birth records

OBJECTIVES: We compared data on race as reported by the mother on North Carolina birth certificates with data on race in officially reported statistics. We also determined to what extent differences in the classification of race affect measures of racial disparity in maternal and child health indicators. METHODS: We examined how data on race are collected, coded, and tabulated in North Carolina via live birth certificates, death certificates, the Behavioral Risk Factor Surveillance System (BRFSS) telephone survey, and the Central Cancer Registry case records. We showed how the data on race collected through North Carolina birth and death certificates are translated into 10 fixed racial categories designated by the National Center for Health Statistics (NCHS) for use in official vital statistics. We compared race as reported by the mother on birth certificates to racial tabulations used in the official published birth statistics. We also examined to what extent differences in the determination of race affect measures of racial disparity in maternal and child health indicators. RESULTS: Out of nearly 118,000 live births in North Carolina in 2002, mothers reported more than 600 different versions of race on birth certificates. These entries were collapsed into the 10 standard racial categories outlined in federal coding rules. Approximately two-thirds of mothers of Hispanic ethnicity report their race with a label that can be categorized as "Other" race, but nearly all of these births are re-coded to "white" for the official birth statistics. Measures of racial disparity vary depending on whether self-reported or officially coded race is used. CONCLUSIONS: This study shows that, given the opportunity to report their own race, North Carolinians describe their race using a wide variety of terms and concepts. In contrast, health statistics are usually reported using a few standardized racial categories defined by federal policy. The NCHS rules for coding race should be reexamined. As the ethnic and racial diversity of the United States continues to increase, these rules will become increasingly antiquated.     

Ascertainment of Medicaid Payment for Delivery on the Iowa Birth Certificate: Is Accuracy Sufficient for Timely Policy and Program Relevant Analysis?

The Iowa Department of Public Health annually links Medicaid claims data to the birth certificate. Because the latest version of the birth certificate provides more timely and less costly information on delivery payment source, we were interested in assessing the validity and reliability of the birth certificate payment source compared to Medicaid paid claims. We linked Medicaid paid claims to birth certificates for calendar years 2007–2009 (n = 120,626). We measured reliability by Kappa statistic and validity by sensitivity, specificity, predictive value positive and negative. We examined reliability and validity overall and by maternal characteristics (e.g. age, race, ethnicity, education). The Kappa statistic for the birth certificate payment source indicated substantial agreement (0.78; 95 % CL 0.78–0.79). Sensitivity and specificity were also high, 86.3 % (95 % CL 86.0–86 6 %) and 91.9 % (95 % CL 91.7–92.1 %), respectively. The predictive value positive was 87.0 %. The predictive value negative was 91.4 %. Kappa and specificity were lower among women of racial and ethnic minorities, women younger than age 24, and women with less education. The overall Kappa, sensitivity and specificity generally suggest the birth certificate payment source is as valid and reliable as the linked data source. The birth certificate payment source is less valid and reliable for women of racial and ethnic minorities, women younger than age 24, and those with less education. Consequently caution should be exercised when using the birth certificate payment source for monitoring service use by the Medicaid population within specific population subgroups.