Gornick ME, Eggers PW, Reilly TW, et al. Effects of race and income on mortality and use of services among Medicare beneficiaries. N Engl J Med 335: 791-799

Health Care Financing Administration, Department of Health and Human Services, Baltimore, MD 21244-1850, USA.
New England Journal of Medicine (Impact Factor: 55.87). 10/1996; 335(11):791-9. DOI: 10.1056/NEJM199609123351106
Source: PubMed


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.
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.
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.
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.

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    • "Thus, in this analysis we focus primarily on older adults living in poverty with varying health insurance statuses. Enabling Factors: Income Most studies examining the association between enabling resources and use of health services incorporate measures of income in some form (Gornick et al., 1996; Hurd & McGarry, 1997; Lum & Chang, 1998). In this analysis, we use income as a means to tease out variations in social behavior—in this case, health service use—between groups living with differing levels of disadvantage. "
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    ABSTRACT: Research on health service utilization among the elderly is unambiguous in finding that those who are the most heavily insured use the most health services. What is less clear, however, is whether the favorable effect of health insurance coverage holds for low-income populations. As such, this study uses data from the Rand version of the Health Retirement Study spanning the years 2002 to 2010 to examine the extent of heterogeneous use of health services within the population of elderly poor and the degree to which health insurance status moderates the effect of poverty on health service utilization.
    Full-text · Article · Jul 2015 · Journal of Poverty
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    • "Compared with whites, blacks are less likely to receive invasive cardiac interventions [4,5], high-cost surgical procedures [6,7], effective preventive care [8,9], medically necessary mental health services [10,11], and new medical technologies [12,13]. By contrast, black patients have significantly higher rates of interventions suggestive of less than optimal management of chronic diseases such as bilateral orchiectomies and lower-extremity amputations [14,15]. Numerous studies have documented that blacks are more likely to obtain care from lower-quality physicians and lower-quality hospitals [3,16-23]. "
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    ABSTRACT: Racial disparities in healthcare in the United States are widespread and have been well documented. However, it is unknown whether racial disparities exist in the use of blood transfusion for patients undergoing major surgery. We used the University HealthSystem Consortium database (2009-2011) to examine racial disparities in perioperative red blood cells (RBCs) transfusion in patients undergoing coronary artery bypass surgery (CABG), total hip replacement (THR), and colectomy. We estimated multivariable logistic regressions to examine whether black patients are more likely than white patients to receive perioperative RBC transfusion, and to investigate potential sources of racial disparities. After adjusting for patient-level factors, black patients were more likely to receive RBC transfusions for CABG (AOR = 1.41, 95% CI: [1.13, 1.76], p = 0.002) and THR (AOR = 1.39, 95% CI: [1.20, 1.62], p < 0.001), but not for colectomy (AOR = 1.08, 95% CI: [0.90, 1.30], p = 0.40). Black-white disparities in blood transfusion persisted after controlling for patient insurance and hospital effects (CABG: AOR = 1.42, 95% CI: [1.30, 1.56], p < 0.001; THR: AOR = 1.43, 95% CI: [1.29, 1.58], p < 0.001). We detected racial disparities in the use of blood transfusion for CABG and THR (black patients tended to receive more transfusions compared with whites), but not for colectomy. Reporting racial disparities in contemporary transfusion practices may help reduce potentially unnecessary blood transfusions in minority patients.
    Full-text · Article · Mar 2014 · BMC Health Services Research
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    • "); and colorectal, breast, lung, or prostate cancer (Gross et al. 2008). As compared with whites, blacks are two-to-three times more likely to undergo bilateral orchiectomies and lower limb amputations due to suboptimal management of chronic diseases (Gornick et al. 1996). Black patients have a 20 percent higher risk of death after a major surgery compared with whites (Lucas et al. 2006). "
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    ABSTRACT: Objective To determine whether outcome disparities between black and white trauma patients have decreased over the last 10years. Data SourcePennsylvania Trauma Outcome Study. Study DesignWe performed an observational cohort study on 191,887 patients admitted to 28 Level 1 and Level II trauma centers. The main outcomes of interest were (1) death, (2) death or major complication, and (3) failure-to-rescue. Hospitals were categorized according to the proportion of black patients. Multivariate regression models were used to estimate trends in racial disparities and to assess whether the source of racial disparities was within or between hospitals. Principal FindingsTrauma patients admitted to hospitals with high concentrations of blacks (>20 percent) had a 45 percent higher odds of death (adj OR: 1.45, 95 percent CI: 1.09-1.92) and a 73 percent higher odds of death or major complication (adj OR: 1.73, 95 percent CI: 1.42-2.11) compared with patients admitted to hospitals treating low proportions of blacks. Blacks and whites admitted to the same hospitals had no difference in mortality (adj OR: 1.05, 95 percent CI: 0.87, 1.27) or death or major complications (adj OR: 1.01; 95 percent CI: 0.90, 1.13). The odds of overall mortality, and death or major complications have been reduced by 32 percent (adj OR: 0.68; 95 percent CI: 0.54-0.86) and 28 percent (adj OR: 0.72; 95 percent CI: 0.60-0.85) between 2000 and 2009, respectively. Racial disparities did not change over 10years. Conclusion Despite the overall improvement in outcomes, the gap in quality of care between black and white trauma patients in Pennsylvania has not narrowed over the last 10years. Racial disparities in trauma are due to the fact that black patients are more likely to be treated in lower quality hospitals compared with whites.
    Full-text · Article · May 2013 · Health Services Research
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