Disparities in Quality of Care for Midlife Adults (Ages 45–64) Versus Older Adults (Ages >65). 2.5 Disparities in Other Priority Conditions: Examples From Cardiovascular Care and Depression

05/01/2012

The paucity of diabetes literature examining quality of care disparities based on individual factors other than race/ethnicity, and which also differentiate between midlife and older adults who have different health insurance coverage situations that could affect care, is similar for other priority conditions. This section briefly highlights the literature for two other conditions commonly related to diabetes: cardiovascular conditions and depression.

Similar to the literature search for age-stratified diabetes disparities, Medline reviews were conducted for cardiovascular care and depression disparities. Reviews were limited to human subjects, English-language cardiovascular care and depression studies published in the last five years, using the broadest search terms possible to maximize the results returned (cardiovascular and disparities, depression and disparities), and to studies that included midlife adults (45–64). The Medline search for cardiovascular disparities yielded 131 studies; the search for depression disparities yielded 71 studies. Of these, only a few could be determined to stratify results by midlife adults vs. older adults (>65) conclusively. This is similar to patterns in the age-stratified diabetes disparities literature, and reconfirms findings that even when the broadest search terms are applied for maximum results, there are gaps in the age-stratified literature for older adult disparities.

Studies of both cardiovascular and depression care disparities focused on race and ethnicity and primarily concluded that non-White minorities receive lower quality of health care compared to Whites. Most studies focused on effectiveness of care, with other IOM quality domains remaining largely unexplored. Fewer studies examined disparities based on other individual factors, such as gender and socioeconomic status. In addition, data were especially lacking on whether disparities differed by age and related health insurance status, with few studies comparing disparities between midlife

In cardiovascular care, for example, one of the largest quality of care studies in recent years found that older non-White minorities had consistently lower process-of-care ratings for cardiovascular care than Whites, such as lower testing and control of LDL levels among patients with known cardiovascular conditions, as well as lower rates of prescription for beta-blocker use after hospitalization for a major cardiovascular event (Trivedi et al 2005). Another comprehensive study of cardiovascular disparities found that non-White racial/ethnic minority Medicare beneficiaries had lower rates of major cardiovascular procedures than Whites, such as coronary-artery bypass grafting (CABG) and carotid endarterectomy (Jha et al 2005).

In the 2008 Health Disparities Report, AHRQ found that obese Hispanics, poor individuals and individuals with lower education were less likely to receive advice about exercise, a recommended process-of-care measure, compared to their White, higher-education and higher-income counterparts (AHRQ 2007). Socioeconomic disparities were also found in a longitudinal study, wherein high income and education individuals experienced much larger declines in smoking, a major risk factor in cardiovascular disease, than low income and education individuals (Kanjilal et al 2006). Studies examining gender disparities had mixed results. One study of Medicare beneficiaries with acute cardiovascular events found that women had higher rates of post-heart attack beta-blocker receipt and cholesterol screening but lower rates of lipid control than men (Bird et al 2007), while another study found that among individuals <65 with cardiovascular conditions, women had higher rates of good blood pressure control, but lower rates of post-heart attack beta-blocker receipt and cholesterol screening (Chou et al 2007; refer to Table 2). The only consistent finding is gender disparities in cholesterol control across age groups; there is positive evidence that disparities in some aspects of cardiovascular care have narrowed over the years (Jha et al 2005; Kanjilal et al 2006; Trivedi et al 2005). Despite their comprehensiveness, these studies did not explicitly address whether disparities based on race/ethnicity continue for both midlife adults and older,

Disparity studies of care for depressive disorders have similar and widely documented evidence of racial/ethnic differences. Across a range of studies, Blacks were found to be at particular risk for undertreatment of depression compared to Whites (AHRQ 2007; Van Voorhees et al 2007; Young et al 2001). In a national overview, both Blacks and Hispanics were found to be less likely to initiate antidepressant medication or psychotherapy for depression than Whites (Harman et al 2004). Furthermore, while existing treatments for depression have been effective across all racial/ethnic groups in community settings, symptomatic recovery is lower among non-White racial/ethnic minorities than Whites (Roy-Byrne et al 2005; Van Voorhees et al 2007). Studies have also documented gender differences in depression, with women reporting rates of depression about twice as high as men across diverse social settings and cultures (WHO 2008). Recent studies have begun to examine quality of care for depression by age, finding older persons to be at risk for lower rates of antidepressant treatment and psychotherapy and less likely to receive a diagnosis of depression (Harman et al 2004). However, as with diabetes and cardiovascular disease, depression care data do not address whether disparities in care persist between midlife and older adults who have different health insurance coverage.

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