@article {13835, title = {Racial and ethnic differences in disease course Medicare expenditures for beneficiaries with dementia.}, journal = {Journal of the American Geriatrics Society}, year = {2024}, abstract = {

BACKGROUND: Research on racial and ethnic disparities in costs of care during the course of dementia is sparse. We analyzed Medicare expenditures for beneficiaries with dementia to identify when during the course of care costs are the highest and whether they differ by race and ethnicity.

METHODS: We analyzed data from the 2000-2016 Health and Retirement Study (HRS) linked with corresponding Medicare claims to estimate total Medicare expenditures for four phases: (1) the year before a dementia diagnosis, (2) the first year following a dementia diagnosis, (3) ongoing care for dementia after the first year, and (4) the last year of life. We estimated each patient{\textquoteright}s phase-specific and disease course Medicare expenditures by using a race-specific survival model and monthly expenditures adjusted for patient characteristics. We investigated healthcare utilization by service type across races/ethnicities and phases of care.

RESULTS: Adjusted mean total Medicare expenditures for non-Hispanic (NH) Black ($165,730) and Hispanic beneficiaries with dementia ($160,442) exceeded corresponding expenditures for NH Whites ($136,326). In the year preceding and immediately following initial dementia diagnosis, mean Medicare expenditures for NH Blacks ($26,337 and $20,429) exceeded expenditures for Hispanics and NH Whites ($21,399-23,176 and 17,182-18,244). The last year of life was responsible for the greatest cost contribution: $51,294 (NH Blacks), $47,469 (Hispanics), and $39,499 (NH Whites). These differences were driven by greater use of high-cost services (e.g., emergency department, inpatient and intensive care), especially during the last year of life.

CONCLUSIONS: NH Black and Hispanic beneficiaries with dementia had higher disease course Medicare expenditures than NH Whites. Expenditures were highest for NH Black beneficiaries in every phase of care. Further research should address mechanisms of such disparities and identify methods to improve communication, shared decision-making, and access to appropriate services for all populations.

}, keywords = {Costs, Dementia, health care disparities, Medicare}, issn = {1532-5415}, doi = {10.1111/jgs.18822}, author = {Olchanski, Natalia and Zhu, Yingying and Liang, Lichen and Cohen, Joshua T and Faul, Jessica D and Fillit, Howard M and Freund, Karen M and Lin, Pei-Jung} } @article {12488, title = {Racial and Ethnic Differences in Hospice Use and Hospitalizations at End-of-Life Among Medicare Beneficiaries With Dementia.}, journal = {JAMA Network Open}, volume = {5}, year = {2022}, pages = {e2216260}, abstract = {

Importance: The pool of studies examining ethnic and racial differences in hospice use and end-of-life hospitalizations among patients with dementia is limited and results are conflicting, making it difficult to assess health care needs of underresourced racial and ethnic groups.

Objective: To explore differences in end-of-life utilization of hospice and hospital services among patients with dementia by race and ethnicity.

Design, Setting, and Participants: This cohort study used national survey data from the Health and Retirement Study linked with Medicare and Medicaid claims that reflected a range of socioeconomic, health, and psychosocial characteristics. Eligible participants were Medicare fee-for-service beneficiaries aged 65 years or older diagnosed with dementia who died between 2000 and 2016. Analyses were performed from June to December 2021.

Exposures: Race and ethnicity.

Main Outcomes and Measures: We examined the frequency and costs of hospice care, emergency department (ED) visits, and hospitalizations during the last 180 days of life among Medicare decedents with dementia. We analyzed the proportion of dementia decedents with advance care planning and their end-of-life care preferences.

Results: The cohort sample included 5058 beneficiaries with dementia (mean [SD] age, 85.5 [8.0] years; 3038 women [60.1\%]; 809 [16.0\%] non-Hispanic Black, 357 [7.1\%] Hispanic, and 3892 non-Hispanic White respondents [76.9\%]). In adjusted analysis, non-Hispanic Black decedents (odds ratio [OR], 0.65; 95\% CI, 0.55-0.78), nursing home residents (OR, 0.81; 95\% CI, 0.71-0.93), and survey respondents represented by a proxy (OR, 0.84; 95\% CI, 0.71-0.99) were less likely to use hospice, whereas older decedents (age 75-84 vs 65-74 years: OR, 1.39; 95\% CI, 1.12-1.72; age >=85 vs 65-74 years: OR, 1.39; 95\% CI, 1.13-1.71), women (OR, 1.19; 95\% CI, 1.05-1.35), and decedents with higher education (high school vs less than high school: OR, 1.17; 95\% CI, 1.01-1.36; more than high school vs less than high school: OR, 1.32; 95\% CI, 1.13-1.54), more severe cognitive impairment (OR, 1.51; 95\% CI, 1.02-2.23), and more instrumental activities of daily living limitations (OR, 1.07; 95\% CI, 1.01-1.12) were associated with higher hospice enrollment. A higher proportion of Black and Hispanic decedents with dementia used ED (645 of 809 [79.7\%] and 274 of 357 [76.8\%] vs 2753 of 3892 [70.7\%]; P < .001) and inpatient services (625 of 809 [77.3\%] and 275 of 357 [77.0\%] vs 2630 of 3892 [67.5\%]; P < .001) and incurred roughly 60\% higher inpatient expenditures at the end of life compared with White decedents (estimated mean: Black, $23 279; 95\% CI, $20 690-$25 868; Hispanic, $23 471; 95\% CI, $19 532-$27 410 vs White, $14 609; 95\% CI, $13 800-$15 418). A higher proportion of Black and Hispanic than White beneficiaries with dementia who were enrolled in hospice were subsequently admitted to the ED (56 of 309 [18.1\%] and 22 of 153 [14.4\%] vs 191 of 1967 [9.7\%]; P < .001) or hospital (48 of 309 [15.5\%] and 17 of 153 [11.1\%] vs 119 of 1967 [6.0\%]; P < .001) before death. The proportion of dementia beneficiaries completing advance care planning was lower among Black (146 of 704 [20.7\%]) and Hispanic (66 of 308 [21.4\%]) beneficiaries compared with White beneficiaries (1871 of 3274 [57.1\%]). A higher proportion of Black and Hispanic decedents with dementia had written instructions choosing all care possible to prolong life (30 of 144 [20.8\%] and 12 of 65 [18.4\%] vs 72 of 1852 [3.9\%]), whereas a higher proportion of White decedents preferred to limit care in certain situations (1708 of 1840 [92.8\%] vs 114 of 141 [80.9\%] and 51 of 64 [79.7\%]), withhold treatments (1448 of 1799 [80.5\%] vs 87 of 140 [62.1\%] and 41 of 62 [66.1\%]), and forgo extensive life-prolonging measures (1712 of 1838 [93.1\%] vs 120 of 138 [87.0\%] and 54 of 65 [83.1\%]).

Conclusions and Relevance: The results of this cohort study highlight unique end-of-life care utilization and treatment preferences across racial and ethnic groups among patients with dementia. Medicare should consider alternative payment models to promote culturally competent end-of-life care and reduce low-value interventions and costs among the population with dementia.

}, keywords = {Activities of Daily Living, Death, Dementia, Female, Hospice Care, Hospices, Hospitalization, Medicare}, issn = {2574-3805}, doi = {10.1001/jamanetworkopen.2022.16260}, author = {Lin, Pei-Jung and Zhu, Yingying and Olchanski, Natalia and Cohen, Joshua T and Neumann, Peter J and Jessica Faul and Fillit, Howard M and Freund, Karen M} } @article {10686, title = {Racial and Ethnic Differences in Knowledge About One{\textquoteright}s Dementia Status}, journal = {Journal of American Geriatrics Society}, year = {2020}, type = {Journal}, abstract = {OBJECTIVES To examine racial and ethnic differences in knowledge about one?s dementia status. DESIGN Prospective cohort study. SETTING The 2000 to 2014 Health and Retirement Study. PARTICIPANTS Our sample included 8,686 person-wave observations representing 4,065 unique survey participants, aged 70?years or older, with dementia, as identified by a well-validated statistical prediction model based on individual demographic and clinical characteristics. MEASUREMENTS Primary outcome measure was knowledge of one?s dementia status, as reported in the survey. Patient characteristics included race/ethnicity, age, sex, survey year, cognition, function, comorbidity, and whether living in a nursing home. RESULTS Among subjects identified as having dementia by the prediction model, 43.5\% to 50.2\%, depending on the survey year, reported that they were informed of the dementia status by their physician. This proportion was lower among Hispanics (25.9\%-42.2\%) and non-Hispanic blacks (31.4\%-50.5\%) than among non-Hispanic whites (47.7\%-52.9\%). Our fully adjusted regression model indicated lower dementia awareness among non-Hispanic blacks (odds ratio [OR] = 0.74; 95\% confidence interval [CI] = 0.58-0.94) and Hispanics (OR = 0.60; 95\% CI = 0.43-0.85), compared to non-Hispanic whites. Having more instrumental activity of daily living limitations (OR = 1.65; 95\% CI = 1.56-1.75) and living in a nursing home (OR = 2.78; 95\% CI = 2.32-3.32) were associated with increased odds of subjects reporting being told about dementia by a physician. CONCLUSION Less than half of individuals with dementia reported being told by a physician about the condition. A higher proportion of non-Hispanic blacks and Hispanics with dementia may be unaware of their condition, despite higher dementia prevalence in these groups, compared to non-Hispanic whites. Dementia outreach programs should target diverse communities with disproportionately high disease prevalence and low awareness.}, keywords = {Cognitive health, Dementia, Health Disparities}, isbn = {0002-8614}, doi = {10.1111/jgs.16442}, url = {https://www.ncbi.nlm.nih.gov/pubmed/32282058}, author = {Lin, Pei-Jung and Emerson, Joanna and Jessica Faul and Joshua T Cohen and Peter J Neumann and Howard M Fillit and Allan T Daly and Margaretos, Nikoletta and Karen M Freund} }