Marian E. Gornick

Effects of race and income on mortality and use of services among Medicare beneficiaries.

BACKGROUND There are wide disparities between blacks and whites in the use of many Medicare services. We studied the effects of race and income on mortality and use of services. METHODS We linked 1990 census data on median income according to ZIP Code with 1993 Medicare administrative data for 26.3 million beneficiaries 65 years of age or older (24.2 million whites and 2.1 million blacks). We calculated age-adjusted mortality rates and age- and sex-adjusted rates of various diagnoses and procedures according to race and income and computed black:white ratios. The 1993 Medicare Current Beneficiary Survey was used to validate the results and determine rates of immunization against influenza. RESULTS For mortality, the black:white ratios were 1.19 for men and 1.16 for women (P<0.001 for both). For hospital discharges, the ratio was 1.14 (P<0.001), and for visits to physicians for ambulatory care it was 0.89 (P<0.001). For every 100 women, there were 26.0 mammograms among whites and 17.1 mammograms among blacks. As compared with mammography rates in the respective most affluent group, rates in the least affluent group were 33 percent lower among whites and 22 percent lower among blacks. The black:white rate ratio was 2.45 for bilateral orchiectomy and 3.64 for amputations of all or part of the lower limb (P<0.001 for both). For every 1000 beneficiaries, there were 515 influenza immunizations among whites and 313 among blacks. As compared with immunization rates in the respective most affluent group, rates in the least affluent group were 26 percent lower among whites and 39 percent lower among blacks. Adjusting the mortality and utilization rates for differences in income generally reduced the racial differences, but the effect was relatively small. CONCLUSIONS Race and income have substantial effects on mortality and use of services among Medicare beneficiaries. Providing health insurance is not enough to ensure that the program is used effectively and equitably by all beneficiaries.

Rehospitalizations after coronary revascularization among Medicare beneficiaries.

The rehospitalization experience of Medicare beneficiaries undergoing coronary artery bypass surgery or percutaneous transluminal coronary angioplasty in 1986 and 1987 was studied by following 53,715 patients who underwent coronary artery bypass and 28,817 patients who underwent angioplasty for 1 year using Medicare hospital claims data. The 1-year rehospitalization rate after bypass and angioplasty was 629 and 863 per 1,000, respectively, compared to a rate of 607 for the Medicare patient population in general. About 45% of rehospitalizations after bypass and two thirds after angioplasty were in categories determined by an expert panel to be possibly related to the original procedure. After angioplasty, there were 61 discharges per 1,000 for bypass surgery and 140 per 1,000 for a repeat angioplasty. Rehospitalization rates for coronary artery bypass surgery after angioplasty were significantly lower for female and black patients who underwent angioplasty. The volume of rehospitalization after revascularizations makes it an important outcome measure. Medicare administrative records provide a unique source of information on rehospitalizations and make possible the monitoring of broad trends in the frequency and outcomes of coronary revascularization. The lower rates of bypass surgery after angioplasty for black and female patients are in line with other studies and bear further investigation.

U.S. initiatives and approaches for outcomes and effectiveness research

This paper provides an overview of the new Federal initiative underway to promote research in outcomes and effectiveness of services provided in the U.S. It discusses the factors that stimulated the U.S. government ot undertake this initiative and summarizes past research and current efforts to advance knowledge about utilization and outcomes of care. A focal point of this initiative is to take advantage of information in large, administrative data bases to monitor the use, costs and outcomes of medical services. As part of this initiative, the Federal Government for the first time assembled detailed data, by geographic area and by demographic groups, on the hospitalization, mortality and rehospitalization experience of the entire Medicare population. The paper describes this project and illustrates uses of these data.