Impact of Massachusetts Health Care Reform on Racial, Ethnic and Socioeconomic Disparities in Cardiovascular Care

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1 Impact of Massachusetts Health Care Reform on Racial, Ethnic and Socioeconomic Disparities in Cardiovascular Care Michelle A. Albert MD MPH Treacy S. Silbaugh B.S, John Z. Ayanian MD MPP, Ann Lovett RN MA, Fred Resnic MD MSc, Sharon-Lise T. Normand PhD Brigham and Women s Hospital, Harvard Medical School Harvard School of Public Health Boston, MA

2 Impact of Massachusetts Health Care Reform on Racial, Ethnic and Socioeconomic Disparities in Cardiovascular Care WE HAVE NO DISCLOSURES

3 Background Well-documented disparities in use of coronary interventions according race/ethnicity and socioeconomic status Blacks less likely to undergo CABG/PCI Potential determinants: Differences in traditional CVD risk factor burden Socioeconomic status Lower quality of care Chronic stress Suboptimal interactions with health care providers Low levels of provider satisfaction/positive effect in the caregiving exchange Access to appropriate health care Mensah G & Dunbar SB, JCN 2006 Lillie-Blanton M et al. JACC 2004 Albert MA et al, 2010

4 Background 2009 United States (U.S) Census data: Un-insured Americans: 50.7 million people Un-insured rates for non-elderly adults: Hispanic: 32.4% Black: 21.0% Asian: 17.0% White: 12.0% Massachusetts rates of un-insurance according to race/ethnicity parallel observed national rates. US Census Bureau Report 2010 Albert MA et al, 2010

5 Massachusetts Health Care Reform Law of 2006 Act Providing Access to Affordable, Quality, Accountable Health Care, Chapter 58 All residents required to have health insurance. Expanded MassHealth (Medicaid). Provided health insurance subsides based on income. Employers with more than 11 employees required to offer health insurance or face fines. Extended health insurance coverage to many uninsured residents: racial/ethnic minorities, < below the Federal poverty level (Disparities council; Community Health Worker Outreach Emerging Post Reform data 2009: racial/ethnic minority adults as a group have similar insurance coverage as whites in the state However, whether the decline in the number of uninsured residents has translated into narrowed disparities in the use of cardiovascular procedures is unknown Long SK and Stockley K, BCBS MA Foundation/Urban Institute 2010

6 Aims Evaluate the impact of Massachusetts health insurance reform on racial/ethnic, socioeconomic and gender disparities in cardiovascular care by determining: 1. Relative rates of coronary revascularization (CABG or PCI) pre and post reform in blacks, Hispanics, and Asian adults aged years compared to whites 2. If relative rates of coronary revascularization have increased for adults according to education level post compared to pre reform 3. Relative rates of coronary revascularization by gender post compared to pre reform 4. In-hospital mortality for patients with ischemic heart disease post compared to pre reform

7 Methods Sources of information: Statewide hospital discharge billing data: Massachusetts Hospital Case Mix and Charge Datasets 2000 US Census Data Analysis cohort: years old Discharge diagnosis: Ischemic Heart Disease (ICD ) Pre reform (November to July ; N= 66, 088) Post reform ( December to September ; N = 65, 419)

8 Methods Study outcomes: Primary outcome: CABG/PCI during hospitalization Secondary outcome: all-cause in hospital mortality Statistical analysis: Logistic Regression Primary covariates: White (N= 108, 349), Black (N= 8, 899) Hispanic (N= 7, 705), Asian (N= 1, 265) Education: % residents high school graduates at zip-code level Gender (Female = 31.2%) Other variables: Age, diabetes, hyperlipidemia, hypertension, smoking, previous MI, previous CABG/PCI, chronic renal insufficiency, chronic lung disease, insurance, congestive heart failure, admission status, cardiogenic shock, peripheral vascular disease, admission status

9 Insurance Rates: Race/Ethnicity Pre-Reform Post-Reform % Albert MA et al, 2010

10 Baseline Characteristics: Race/Ethnicity Whites (N=106,349) Pre-Reform (N=53,994) Post-Reform (N=52,355) p-value Age (years), SD 55.5 (7.1) 55.6 (7.0) NS Female sex (%) NS Diabetes mellitus (%) NS Hyperlipidemia (%) <0.001 Hypertension (%) <0.001 Current smoker (%) <0.001 Previous myocardial infarction (%) Chronic renal insufficiency (%) <0.001 <0.001 Blacks (N=8,899) Pre-Reform Post-Reform p-value (N=4,195) (N=4,704) Age (years), SD 53.4 (8.1) 53.6 (8.0) NS Female sex (%) NS Diabetes mellitus (%) <0.001 Hyperlipidemia (%) <0.001 Hypertension (%) NS Current smoker (%) <0.001 Previous myocardial infarction (%) Chronic renal insufficiency (%) NS <0.001 NS = Not significant Albert MA et al, 2010

11 Baseline Characteristics: Race/Ethnicity Hispanic (N=7,705) Pre-Reform (N=3,764) Post-Reform (N=3,941) p-value Age (years), SD 53.4 (7.9) 53.3 (8.1) NS Female sex (%) NS Diabetes mellitus (%) NS Hyperlipidemia (%) <0.001 Hypertension (%) <0.001 Current smoker (%) <0.001 Previous myocardial infarction (%) Chronic renal insufficiency (%) <0.001 Asian (N=1,265) Pre-Reform (N=540) Post-Reform p-value (N=725) Age (years), SD 54.1 (7.9) 54.3 (7.5) NS Female sex (%) NS Diabetes mellitus (%) NS Hyperlipidemia (%) <0.001 Hypertension (%) NS Current smoker (%) Previous myocardial infarction (%) Chronic renal insufficiency (%) NS NS 0.05 Albert MA et al, 2010

12 Baseline Characteristics: Race/Ethnicity Summary Whites: Hyperlipidemia, Chronic lung disease, Neoplasms Elective procedures Blacks: Congestive Heart Failure, Chronic Renal Insufficiency Hispanics: Younger (along with blacks) Asians: Neoplasms (post-reform) Decrease in emergency department triage (pre: 49.6% versus post: 44.9%, p <0.001)

13 Baseline Characteristics Post-Reform: Education < 79.6% % >88.6% p-value HS Grad HS Grad HS Grad Post-Reform (N=65419) (N=21,765) (N=22,538) (N=21,116) Age (years), SD 54.6 (7.5) 55.2 (7.1) 55.9 (6.9) <0.001 Female sex (%) <0.001 Race or ethnic group (%) White Black Hispanic Asian <0.001 Insurance (any, %) Diabetes (%) Hypertension (%) Hyperlipidemia (%) Current smoker (%) <0.001 NS <0.001 <0.001 <0.001 Admission status (%) Emergent/urgent <0.001 Albert MA et al, 2010

14 Odds of CABG-PCI (95%CI) and In-Hospital Mortality Pre and Post MA Health Care Reform Albert MA et al, 2010

15 Predictors of Revascularization and In-Hospital Mortality CABG or PCI Decreased Likelihood Previous history of MI Chronic lung disease Neoplasm Female Blacks < High school education Increased Likelihood Hyperlipidemia Diabetes Cardiogenic Shock Elective admission Asian In-Hospital Mortality Elective Hyperlipidemia Cardiogenic Shock Neoplasm GI Diagnosis

16 Potential Limitations Hospital billing and Census data Unmeasured confounders No angiographic information Race/ethnic misclassification Generalizability Within group evaluation: STE MI/ACS Examined all IHD discharges: Sensitivity analyses Albert MA et al, 2010

17 Summary Thus far, with Massachusetts Health Care Reform: 1. Insurance rates are greater among demographic groups. 2. Blacks: no change in lower procedure rates and lower mortality rates 3. Asians: higher procedure rates and no difference in mortality rates 4. Hispanics: essentially equivalent procedure and mortality rates 5. Lower procedure rates and higher mortality for less educated communities post-reform 6. Lower procedure rates and equivalent mortality for women relative to men in both time periods Albert MA et al, 2010

18 Implications Reducing insurance barriers has not yet eliminated preexisting disparities Elimination of disparities might be achieved through action plans that focus on them as a health care quality issue Potential Interventions: Systematic collection of demographic data Financial reimbursement: vulnerable groups Discrimination: health quality and outcome Provider workforce diversification and advancement Targeted education, screening and treatment Albert MA et al, 2010

19 Acknowledgements Collaborators Tracey Silbaugh Sharon-Lise Normand Ann Lovett John Ayanian Fred Resnic Katya Zelvinsky Robert Wolf Matthew Cioffi Nitsan Halevy Division of Health Care Finance and Policy, Commonwealth of Massachusetts Harvard Catalyst Program (UL RR 02578) H. Richard Nesson Award Mentors Paul M Ridker Elliot Antman Peter Libby Julie Buring Myron Weisfeldt

20 Dedicated to the Memory of Caroline Cecilia Albert (March 1920 September 2010) Thank You.

21 Quality of healthcare Non Minority Minority Institute of Medicine: Understanding the Sources of Healthcare Disparities Difference Clinical appropriateness & need Patient preferences Ecology of healthcare systems Environmental Factors Discrimination: biases, stereotyping, uncertainty Disparity IOM, 2002

22 BACKUP SLIDES

23 Public s Perception of Disparities in Healthcare Black bars somewhat often White bars somewhat often Lillie-Blanton et al, 2004

24 Public s Perception of Quality of Care: Race/Ethnicity Black bars lower quality White bars same quality Gray bars higher quality Lillie-Blanton et al, 2004

25 Race/Ethnic Differences in Cardiac Care Lillie-Blanton et al, 2004

26 Odds Ratios (95% CI) for CABG-PCI: Education Crude a Adjusted b >High High School No High School >High High School No High School School School Pre-reform PCI +/- stenting (0.78, 0.86) 0.62 (0.59, 0.68) (0.80, 0.88) 0.66 (0.63, 0.70) CABG or PCI (0.79, 0.87) 0.63 (0.60, 0.66) (0.81, 0.89) 0.67 (0.64, 0.71) Post-reform PCI +/- stenting (0.76, 0.84) 0.56 (0.53, 0.59) (0.76, 0.85) 0.58 (0.55, 0.62) CABG or PCI (0.77, 0.85) 0.57 (0.54, 0.60) (0.77, 0.85) 0.60 (0.57, 0.64) a Crude model includes age, sex, patient admission status and co-morbidities b Adjusted model includes model a + race/ethnicity

27 Odds Ratios (95% CI) for CABG-PCI: Gender Crude a Adjusted b Males Females Males Females Pre-reform PCI +/- stenting (0.54, 0.60) (0.57, 0.63) CABG or PCI (0.48, 0.53) (0.50, 0.55) Post-reform PCI +/- stenting (0.54, 0.60) (0.57, 0.64) CABG or PCI (0.48, 0.53) (0.50, 0.55) a Crude model includes age, sex, patient admission status and co-morbidities b Adjusted model includes model a + education

28 Years of Potential Life Lost (YPLL) before age 75 CDC, 2001 Mensah & Dunbar, 2006

29 Contributing Factors to Healthcare Disparities in Chronic Disease Late diagnosis due to limitations in awareness Disparities in quality of care for Blacks, Poor: Less likely to reach treatment goals/standards Less likely to have access to new technology for diagnosis and treatment Limitation in cultural competence among healthcare provider Special concerns in rural areas: Increased rates of poverty Lack of access to providers, technology and procedures Disparities in quality of care (see above) Low levels of confidence in healthcare providers and healthcare system among health disparate populations Low levels of provider satisfaction/positive effect when caring for health disparate population. Crooks & Peters, 2008

30 Baseline Characteristics: Race/Ethnicity Whites (N=106,349) Pre-Reform (N=53,994) Post-Reform (N=52,355) p-value Insurance no. (%) Self-pay <.001 Free-care All Other Congestive heart failure no. (%) NS Chronic lung disease no. (%) <.001 Chronic renal insufficiency no. (%) <.001 Cardiogenic shock no. (%) NS Blacks (N=8,899) Pre-Reform (N=4,195) Post-Reform (N=4,704) p-value Insurance no. (%) Self-pay <.001 Free-care All Other Congestive heart failure no. (%) NS Chronic lung disease no. (%) Chronic renal insufficiency no. (%) <.001 Cardiogenic shock no. (%) Albert MA et al, 2010

31 Baseline Characteristics: Race/Ethnicity Hispanic (N=7,705) Pre-Reform (N=3,764) Post-Reform (N=3,941) p-value Insurance no. (%) Self-pay <.001 Free-care All Other Congestive heart failure no. (%) Chronic lung disease no. (%) <.001 Chronic renal insufficiency no. (%) <.001 Cardiogenic shock no. (%) NS Asian (N=1,265) Pre-Reform (N=540) Post-Reform p-value (N=725) Insurance no. (%) Self-pay <.001 Free-care All Other Congestive heart failure no. (%) NS Chronic lung disease no. (%) NS Chronic renal insufficiency no. (%) Cardiogenic shock no. (%) Albert MA et al, 2010

32 Odds Ratios (95% CI) for CABG-PCI: Race/Ethnicity White Black Hispanic Asian Pre-reform PCI +/- stenting a (0.47, 0.59) 0.71 (0.64, 0.78) 1.22 (0.98, 1.51) PCI +/- stenting b (0.53, 0.66) 0.83 (0.74, 0.92) 1.28 (1.03, 1.58) CABG or PCI a (0.44, 0.54) 0.71 (0.64, 0.78) 1.42 (1.16, 1.74) CABG or PCI b (0.49, 0.61) 0.83 (0.75, 0.92) 1.50 (1.21, 1.82) Post-reform PCI +/- stenting a (0.47, 0.59) 0.73 (0.65, 0.81) 1.50 (1.25, 1.82) PCI +/- stenting b (0.55, 0.69) 0.89 (0.79, 0.99) 1.55 (1.28, 1.87) CABG or PCI a (0.44, 0.55) 0.71 (0.64, 0.79) 1.76 (1.48, 2.11) CABG or PCI b (0.51, 0.64) 0.86 (0.77, 0.95) 1.82 (1.52, 2.18) a Crude model includes age, sex, patient admission status and co-morbidities b Adjusted model includes age, sex, education, patient admission status and co-morbidities Albert MA et al, 2010

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