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Hemoglobin A1c Testing and Amputation Rates in Black, Hispanic, and White Medicare Patients.

ABSTRACT: Major (above-knee or below-knee) amputation is a complication of diabetes and is seen more common among black and Hispanic patients. While amputation rates have declined for patients with diabetes in the last decade, it remains unknown if these improvements have equitably extended across racial groups and if measures of diabetic care, such as hemoglobin A1c testing, are associated with these improvements. We set out to characterize secular changes in amputation rates among black, Hispanic, and white patients, and to determine associations between hemoglobin A1c testing and amputation risk.We identified 11,942,840 Medicare patients (55% female) with diabetes over the age of 65 years between 2002 and 2012 and followed them for a mean of 6.6 years. Of these, 86% were white, 11.5% were black, and 2.5% were Hispanic. We recorded the occurrence of major amputation and hemoglobin A1c testing during this time period and studied secular changes in amputation rate by race (black, Hispanic, and white). Finally, we examined associations between amputation risk and hemoglobin A1c testing. We measured both the presence of any testing and testing consistency using 3 categories: poor consistency (hemoglobin A1c testing in 0-50% of years), medium consistency (testing in 50-90% of years), and high consistency (testing in >90% of the years in the cohort).Between 2002 and 2012, the average major lower-extremity amputation rate in diabetic Medicare patients was 1.78 per 1,000 per year for black patients, 1.15 per 1,000 per year for Hispanic patients, and 0.56 per 1,000 per year for white patients (P < 0.001). Over the study period, the incidence of major amputation in Medicare patients with diabetes declined by 54%, from 1.15 per 1,000 in 2002 to 0.53 per 1,000 in 2012 (rate ratio = 0.53, 95% CI = 0.51-0.54). The reduction in amputation rate was similar across racial groups: 52% for black patients, 61% for Hispanic patients, and 55% for white patients. In multivariable analysis adjusting for patient characteristics, including race, any use of hemoglobin A1c testing was associated with a 15% decline in amputation risk (hazard ratio, 0.85; 95% CI, 0.83-0.87; P < 0.001). High consistency hemoglobin A1c testing was associated with a 39% decline in amputation (hazard ratio, 0.61; 95% CI, 0.59-0.62; P < 0.0001).Although more frequent among racial minorities, major lower-extremity amputation rates have declined similarly across black, Hispanic, and white patients over the last decade. Hemoglobin A1c testing, particularly the consistency of testing over time, may be an effective component metric of longitudinal quality measures toward limiting amputation in all races.

SUBMITTER: Suckow BD

PROVIDER: S-EPMC5064433 | biostudies-literature | 2016 Oct

REPOSITORIES: biostudies-literature

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Hemoglobin A1c Testing and Amputation Rates in Black, Hispanic, and White Medicare Patients.

Suckow Bjoern D BD Newhall Karina A KA Bekelis Kimon K Faerber Adrienne E AE Gottlieb Daniel J DJ Skinner Jonathan S JS Stone David H DH Goodney Philip P PP

Annals of vascular surgery 20160727

<h4>Background</h4>Major (above-knee or below-knee) amputation is a complication of diabetes and is seen more common among black and Hispanic patients. While amputation rates have declined for patients with diabetes in the last decade, it remains unknown if these improvements have equitably extended across racial groups and if measures of diabetic care, such as hemoglobin A1c testing, are associated with these improvements. We set out to characterize secular changes in amputation rates among bla ...[more]

PMID: 27474195

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Project description:BackgroundProposed payment reforms in the US healthcare system would hold providers accountable for the care delivered to an assigned patient population. Annual hemoglobin A1c (HbA1c) tests are recommended for all diabetics, but some patient populations may face barriers to high quality healthcare that are beyond providers' control. The magnitude of fine-grained variations in care for diabetic Medicare beneficiaries, and their associations with local population characteristics, are unknown.MethodsHbA1c tests were recorded for 480,745 diabetic Medicare beneficiaries. Spatial analysis was used to create ZIP code-level estimated testing rates. Associations of testing rates with local population characteristics that are outside the control of providers--population density, the percent African American, with less than a high school education, or living in poverty--were assessed.ResultsIn 2009, 83.3% of diabetic Medicare beneficiaries received HbA1c tests. Estimated ZIP code-level rates ranged from 71.0% in the lowest decile to 93.1% in the highest. With each 10% increase in the percent of the population that was African American, associated HbA1c testing rates were 0.24% lower (95% CI -0.32--0.17); for identical increases in the percent with less than a high school education or the percent living in poverty, testing rates were 0.70% lower (-0.95--0.46) and 1.6% lower (-1.8--1.4), respectively. Testing rates were lowest in the least and most densely populated ZIP codes. Population characteristics explained 5% of testing rate variations.ConclusionsHbA1c testing rates are associated with population characteristics, but these characteristics fail to explain the vast majority of variations. Consequently, even complete risk-adjustment may have little impact on some process of care quality measures; much of the ZIP code-related variations in testing rates likely result from provider-based differences and idiosyncratic local factors not related to poverty, education, or race.

Project description:ImportanceSubstantial quality improvements in neonatal care have occurred over the past decade yet racial and ethnic disparities in morbidity and mortality remain. It is uncertain whether disparate patterns of care by race and ethnicity contribute to disparities in neonatal outcomes.ObjectivesTo examine differences in neonatal morbidity and mortality rates among non-Hispanic black (black), Hispanic, and non-Hispanic white (white) very preterm infants and to determine whether these differences are explained by site of delivery.Design, setting, and participantsPopulation-based retrospective cohort study of 7177 nonanomalous infants born between 24 and 31 completed gestational weeks in 39 New York City hospitals using linked 2010 to 2014 New York City discharge abstract and birth certificate data sets. Mixed-effects logistic regression with a random hospital-specific intercept was used to generate risk-adjusted neonatal morbidity and mortality rates for very preterm infants in each hospital. Hospitals were ranked using this measure, and differences in the distribution of black, Hispanic, and white very preterm births were assessed among these hospitals. The statistical analysis was performed in 2016-2017.ExposureRace/ethnicity.Main outcomes and measuresComposite of mortality (neonatal or in-hospital up to 1 year) or severe neonatal morbidity (bronchopulmonary dysplasia, severe necrotizing enterocolitis, retinopathy of prematurity stage 3 or greater, or intraventricular hemorrhage grade 3 or greater).ResultsAmong 7177 very preterm births (VPTBs), morbidity and mortality occurred in 2011 (28%) and was higher among black (893 [32.2%]) and Hispanic (610 [28.1%]) than white (319 [22.5%]) VPTBs (2-tailed P < .001). The risk-standardized morbidity and mortality rate was twice as great for VPTB infants born in hospitals in the highest morbidity and mortality tertile (0.40; 95% CI, 0.38-0.41) as for those born in the lowest morbidity and mortality tertile (0.16; 95% CI, 0.14-0.18). Black (1204 of 2775 [43.4%]) and Hispanic (746 of 2168 [34.4%]) VPTB infants were more likely than white (325 of 1418 [22.9%]) VPTB infants to be born in hospitals in the highest morbidity and mortality tertile (2-tailed P < .001; black-white difference, 20%; 95% CI, 18%-23% and Hispanic-white difference, 11%; 95% CI, 9%-14%). The largest proportion of the explained disparities can be attributed to differences in infant health risks among black, Hispanic, and white VPTB infants. However, 40% (95% CI, 30%-50%) of the black-white disparity and 30% (95% CI, 10%-49%) of the Hispanic-white disparity was explained by birth hospital.Conclusions and relevanceBlack and Hispanic VPTB infants are more likely to be born at hospitals with higher risk-adjusted neonatal morbidity and mortality rates, and these differences contribute to excess morbidity and mortality among black and Hispanic infants.

Project description:ImportanceThe Comprehensive Care for Joint Replacement (CJR) model was designed to reduce the cost and improve the quality of hip or knee replacement among Medicare beneficiaries. Yet whether this model may exacerbate existing racial/ethnic disparities in access to the surgery is unclear.ObjectiveTo examine the association of the CJR model with the receipt of elective hip or knee replacement across White, Black, and Hispanic Medicare beneficiaries.Design, setting, and participantsRetrospective cohort study of Medicare claims from 2013 through 2017 among White, Black, and Hispanic Medicare beneficiaries undergoing elective joint replacement in 65 treatment (selected for CJR participation) and 101 control metropolitan statistical areas (MSAs).ExposuresStarting in April 2016, hospitals in the treatment MSAs were required to participate in the CJR model and were accountable for expenditures occurring during patients' hospitalization for hip or knee replacement and 90 days after the hospital discharge.Main outcomes and measuresBeneficiary-level elective hip or knee replacement receipt in a given year.ResultsAmong 17 243 304 patients, 9 839 996 (57%) were women; 2 107 425 (12%) were age 85 years or older. Of the final sample, 14 632 434 (85%) were White beneficiaries, 1 518 629 (9%) were Black beneficiaries, and 1 092 241 (6%) were Hispanic beneficiaries. The CJR model was associated with an increase of 1.6 elective hip or knee replacements per 1000 beneficiary-years for Hispanic beneficiaries (95% CI, 0.06-2.05) and a decrease of 0.64 replacements for Black beneficiaries (95% CI, -1.25 to -0.02). No evidence was found for any changes for White beneficiaries per 1000 beneficiary-years (0.04 replacements, 95% CI, -0.35 to 0.42 replacements). The Black-White difference in the rate of elective hip or knee replacement per 1000 beneficiary-years further widened by 0.68 replacements (-0.68, 95% CI, -1.20 to -0.15).Conclusions and relevanceIn this cohort study, the CJR model was associated with increased receipt of elective hip or knee replacement among Hispanic beneficiaries, decreased receipt among Black beneficiaries, and no change in receipt among White beneficiaries. The decreased receipt of elective hip or knee replacement among Black beneficiaries may suggest that value-based payment models, including the CJR model, could be monitored for unintended consequences. However, the lack of similar findings among Hispanic beneficiaries suggests that payment models may have differential impacts across racial/ethnic groups.

Project description:ObjectiveResearch suggests a difference in sweet taste perception between non-Hispanic black (NHB) and non-Hispanic white (NHW) adults; however, limited research has examined sweet taste perception in relation to the dietary intake of sweet products. The aim of this study was to examine sweet taste perception and the consumption of sweet foods, beverages, and sugar in NHB and NHW adults, and to evaluate whether sweet taste perception is associated with dietary intake.MethodsThis cross-sectional study examined the association between race, sweet taste perception and sweet food, beverages, and sugar consumption in healthy, NHB and NHW adults. Seven day food records were analyzed in Nutrition Data System for Research software. Intensity of sweet taste perception was tested and the general labeled magnitude scale method was used to facilitate group comparisons. Independent t tests, Mann-Whitney tests, and Pearson correlations were used to assess associations.ResultsParticipants were NHB (n = 98) and NHW (n = 90) adults, 41 ± 1 y of age (mean ± SEM) with energy intake of 2271 ± 53 kcal. Body mass index was higher in NHBs than in NHWs (36 ± 1 versus 32 ± 1 kg/m2, P = 0.048), but no differences were observed in age, energy consumption, or total sugar intake. Sweet taste perception rating (median [interquartile range] NHB: 73.5 [63.9-83], NHW: 52.1 [46.4-57.7]; P = 0.001) and added sugar intake (NHB: 39.4 g/1000 kcal [36.3-42.4], NHW: 30 g/1000 kcal [26.7-33.4]; P < 0.001) were greater in NHB. Perceived sweet taste intensity was positively associated with consumption of servings of sweet products among NHBs (R2 = 0.057, P = 0.018) but not NHWs (R2 = -0.012, P = 0.314).ConclusionsNHBs have a higher intensity of sweet taste perception than NHWs. The positive association of sweet taste perception and sweet product consumption in NHBs suggests that a higher intensity of sweet taste perception may be associated with an increased proportion of energy consumption from added sugars.

Dataset Information

Hemoglobin A1c Testing and Amputation Rates in Black, Hispanic, and White Medicare Patients.

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Hemoglobin A1c Testing and Amputation Rates in Black, Hispanic, and White Medicare Patients.

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