Disparities in Quality of Care for Midlife Adults (Ages 45–64) Versus Older Adults (Ages >65). 1.0 Introduction


In 2011, the first of the post-World War II "baby boom"; generation will reach age 65 and become eligible for Medicare. The cost implications of the entry of baby boomers into Medicare have been widely discussed (Keehan et al 2008) but less attention has been paid to the implications for health care quality. The health insurance characteristics of the United States population changes sharply at age 65, when most individuals become eligible for Medicare, yet evidence on the health effects of Medicare is surprisingly limited (Card et al 2007). Studies have found that use of health care services increases once individuals become eligible for Medicare (McWilliams et al 2007), and disparities in the use of these services by race and income have diminished since Medicare's implementation (National Academy of Social Insurance [NASI] 2006). However, the impact of these additional services on quality of health care and outcomes is less clear. Studies of mortality rates before and after the introduction of Medicare show minimal program impact (Card et al 2007; Finkelstein and McKnight 2005). Studies focusing on use of services before and after Medicare eligibility do not clearly identify whether increased service use translates

Improvements in quality of care on the onset of Medicare eligibility may produce substantial health benefits and improved health outcomes, such as long-term reductions in health care expenditures and healthier populations with less intensive health care needs, but differences in quality of care before and after the onset of Medicare eligibility have not been widely examined. Thus, Medicare's effect on quality

Recognizing that Medicare has had a well-documented effect on reducing disparities in access to care by race and income, the purpose of this report is to better understand how disparities in care quality—based on gender, race/ethnicity, education, income or other socioeconomic factors—may affect the health care system as baby boomers enter

  1. A conceptual framework for monitoring quality of care disparities for midlife adults (ages 45–64) and older adults (ages >65), based on gender, health insurance status, race/ ethnicity, education, income and other key socioeconomic factors. To maximize its applicability, this is a broad-based, non-disease-specific framework that anchors its definition of quality of care in the IOM's domains for quality of care: safe, effective, patient-centered, timely/accessible, equitable and efficient.
  2. A summary of key findings from the literature on disparities in quality of care among midlife and older adults, with a primary focus on diabetes and a secondary focus on cardiovascular conditions and other diabetes-related conditions. The literature review considered disparities based on gender, race/ethnicity, education, insurance and socioeconomic status, and reflecting the IOM's domains of safe, effective, patient-centered, timely/accessible and efficient care.
  3. Quantitative analyses to explore patterns of quality of care disparities among midlife and older adults. This report provides new evidence on effectiveness, timeliness and patient-centeredness of care for those with diabetes or cardiovascular disease. Two separate analyses were conducted. The first analysis examined bivariate patterns in quality of care by gender and race/ethnicity. For a better understanding of gender differences and the explicit role of health insurance coverage, a second analysis examined both bivariate and multivariate associations of quality of care to gender and health insurance status.
  4. A discussion of the findings, policy implications and recommendations for research in quality of care among older adults.

This report focuses on diabetes because it is one of the most prevalent and costly conditions in older adults (Congressional Budget Office 2005; Hogan et al 2001). Measurement of quality care in diabetes is fairly advanced, with numerous well-established diabetes quality of care indicators existing in large, national databases. Furthermore, diabetes is an ideal condition to include in a quality of care disparities study because the negative health outcomes associated with the disease can be minimized through effective management and quality care. A secondary focus on cardiovascular conditions and disparities in depression care are also included because, like
diabetes, cardiovascular conditions are also prevalent and costly among older adults and are associated with diabetes. Measurement of quality of care in cardiovascular conditions is also fairly advanced, with well-established indicators. Depression quality of care indicators are relatively less well developed, but depression is also associated with diabetes and is a costly condition in older adults (refer to Frayne et al 2005).

This report follows a "three-study"; format and is written as three separate manuscripts (presented here as Chapters 2–4) intended as stand-alone chapters. Chapter 2 (Manuscript 1) presents a conceptual framework and reviews the current literature as it relates to disparities in quality of care among midlife and older adults, with a primary focus on diabetes and a secondary focus on cardiovascular and other related conditions. Chapter 3 (Manuscript 2) presents a quantitative analysis characterizing bivariate associations of diabetes and cardiovascular care quality to gender and race/ethnicity. Chapter 4 (Manuscript 3) presents a quantitative analysis characterizing both bivariate and multivariate associations of care quality to gender and health insurance status. While there is, by necessity, some overlap in the research methods used in Chapters 3 and 4, the report attempts to minimize repetition by referring to previous relevant

Chapter 5 discusses gaps in the knowledge base, summarizes key findings presented in the previous chapters and presents key policy recommendations.

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