Minorities more likely to receive low-value care

Black and Hispanic patients received more low-value care than whites, according to a study of Medicare data from between 2006 to 2011 published in the June 2017 issue of Health Affairs.

The study, led by Yale health policy PhD candidate William Schpero, evaluated 11 different services identified as low-value by the Choosing Wisely initiative begun by the American Board of Internal Medicine. Those services included inappropriate provision of imaging for low-back pain, imaging for benign prostatic hypertrophy (BPH), cardiac screening, cervical cancer screening, dual-energy x-ray absorptiometry (DXA) to test bone density, cardiac testing before cataract surgery, cardiac testing before other noncardiac surgery; vitamin D screening, antipsychotic medications in patients with dementia, feeding tubes in patients with advanced dementia, and opioids or butalbital in patients with migraines.

Schpero and his coauthors found receipt of these low-value services was “demonstrably higher” among black and Hispanic patients. One notable difference was for feeding tubes in patients with advanced dementia. Fewer than 5 percent of white Medicare patients received the treatment, compared to nearly 13 percent of Hispanic patients and more than 17 percent of black patients.

“Our findings suggest a possible double jeopardy for minority patients: Long understood to be at risk of receiving less effective care, they also appear to be often at risk of receiving more ineffective care,” Schpero and his coauthors wrote.

After adjusting for covariates, black patients’ receipt of low-value services was “significantly higher” than white patients for five of the 11 services. For Hispanic patients, it was six of the 11. For four services—antipsychotics in patients with dementia, imaging for low-back pain, cervical cancer screening and vitamin D screening—both groups received that kind of care less often than whites.

The results showed that improving access to care isn’t enough to eliminate racial disparities in the healthcare system. The authors concluded by suggesting policymakers have to target both the “experience of minority patients” and the “complex interplay between underuse and overuse of care.”

"Healthcare performance metrics are now beginning to specifically target disparities,” Schpero and his coauthors wrote. “Experimentation with such metrics tied to incentive regimes may accelerate the correction of the long-understood racial and ethnic differences in care that our study reveals to be multidimensional.”