Disparities in Quality of Care for Midlife Adults (Ages 45–64) Versus Older Adults (Ages >65). 4.0 Association of Delays, Effectiveness and Patient-Centeredness in Health Care With Age, Gender and Insurance Status Among Americans With Diabetes and Cardiovascular Conditions

Collectively, diabetes and cardiovascular disease account for nearly 30 percent of all deaths in the U.S. and an estimated $623 billion in direct and indirect medical costs (AHRQ 2008; CDC 2009). These diseases are among the most prevalent chronic conditions in midlife and older adult populations 45 and older. Their impact on overall health and disability is profound, but can be minimized through effective management and quality care.

There have been significant efforts to evaluate the quality of diabetes and cardiovascular care among midlife and older adult populations. Current literature suggests that access to care and receiving needed care are key issues among midlife adults (45–64), many of whom have chronic conditions (Collins et al 2006; Hoffman and Schwartz 2008; McWilliams et al 2003). The literature further suggests that Medicare improves access to care and reduces disparities in use of services for virtually all older adults 65 and older who are eligible for coverage (NASI 2006; Williams 2004).

However, while there have been evaluations of quality of care for diabetes and cardiovascular conditions, few large-scale studies have considered health insurance status. Health insurance coverage may affect the ability to pay for care and access to care, particularly timeliness of care, and women may be differentially affected (Glied et al 2008; Patchias and Waxman 2007; Rustgi et al 2009). Existing studies have not often provided comparative results from the Medicare population, which has high rates of chronic conditions but whose insurance status differs from midlife adults. Nor have studies always differentiated between the experiences of women and men, despite previous literature demonstrating gender disparities in select diabetes and cardiovascular outcomes, such as increased risk of diabetes complications and under-receipt of appropriate clinical procedures among women (Chou et al 2007a, 2007b).

This chapter examines the relationship of age, gender and insurance status to quality of care—particularly timeliness of care—among Americans with diabetes and cardiovascular conditions. Using a large-scale, nationally representative survey, this study examined whether gender and insurance are related to self-reported delays in care among midlife adults (45–64) and older adults (>65) with diabetes and cardiovascular conditions.

Nationally representative MEPS data were used to examine the relationship of age, gender and insurance status to quality of care among Americans with diabetes and cardiovascular conditions. Persons with missing education or insurance status data were excluded from the analysis (6 percent each for the diabetes and cardiovascular condition populations). Older adults who reported being "uninsured"; were excluded from analysis because they are eligible for Medicare and because there were few respondents who indicated that they were uninsured (0.1 percent each for the diabetes and cardiovascular condition populations). This study focused on respondents ≥45 with self-identified diabetes (N=4,067) or self-identified cardiovascular conditions (N=17,636). Refer to Chapter 3.2 for additional information about the

Analytic Variables

Dependent Variables

The dependent variables were 17 qualities of care indicators for diabetes and 15 qualities of care indicators for cardiovascular conditions. The indicators were from MEPS and addressed effectiveness, timeliness (delays) and patient-centeredness of care (Table 3). Of the 17 diabetes indicators, 7 measured effectiveness of care, 5 measured timeliness of care and 5 measured patient-centeredness of care. Of the 15 cardiovascular indicators, 5 measured effectiveness of care, 5 measured timeliness and 5 measured patient-centeredness items.

Six of the seven diabetes effectiveness of care indicators asked respondents if they had received HbA1c testing, an eye examination, a foot examination, blood pressure testing, blood cholesterol testing and influenza shot. The seventh indicator was a composite measure that examined whether respondents had received HbA1c testing and an eye and foot examination. The five cardiovascular effectiveness of care indicators asked respondents if they had received dietary advice, exercise advice, blood pressure testing, blood cholesterol testing and an influenza shot. All indicators asked about patient experiences during the past year.

The five timeliness indicators were the same for diabetes and cardiovascular condition patients. Three indicators asked all respondents if they had delays in obtaining medical care, dental care or prescription medications. A fourth indicator was a composite measure that asked respondents if they had a delay in any of these three types of care. The fifth indicator was concerned with whether patients who needed care for illness or injury actually received care as soon as they wanted it. All items asked about patient experiences during the past year.

The five patient-centeredness indicators were the same for diabetes and cardiovascular condition patients. Four items asked all respondents if their provider listened carefully, explained things clearly, showed respect and spent enough time with them. The fifth indicator was a composite measure that asked respondents if their provider did any of these four things. All indicators asked about patient experiences during the past year.

Independent Variables

The main independent variables of interest were age, gender and health insurance status in the past year. Age was stratified by midlife adults (45–64 years) vs. older adults (≥65 years). Gender was coded as "male"; or "female."; Five mutually-exclusive insurance status categories were based on self-reported insurance coverage, differentiated by midlife adults vs. older adults. All midlife adults were coded according to whether they reported having private health insurance in the previous year (including health insurance through an employer or union or a private source that was not employment-related); having only public insurance in the previous year (including Medicare, TRICARE, Medicaid and other public hospital/physician coverage); or being uninsured for all of the previous year. Older adults were coded according to whether they reported having Medicare and private health insurance in the previous year, or whether they had Medicare alone or Medicare in combination with only public insurance in the previous year. Older adults who reported being uninsured were excluded because this category had very few

Covariates were race/ethnicity (non-Hispanic White, non-Hispanic Black or Hispanic of any race); education level (<high school or >some college); income level (poor, near poor or low [representing <200 percent federal poverty level (FPL)]) vs. middle or high income (representing >200 FPL); and self-rated health status (excellent, very good or good vs. fair or poor).

Data Analysis

A multivariate analysis was performed using SAS version 9.2 (SAS Institute, Cary, NC) and SUDAAN Release 10.0.0 (RTI International, Research Triangle Park, NC). All estimates were weighted to reflect the complex survey sampling design. Variance was computed using the Taylor linearization method, taking sample design features into account using SUDAAN. The individual was the unit of analysis. The unadjusted associations of all quality indicators were compared across age, gender and insurance status groups. Because of data limitations, reliable unadjusted estimates (with minimum cell size criteria of 100 observations or relative standard error >0.3) were not possible for all age groups, insurance status and gender strata, and unreliable estimates were suppressed in the unadjusted tables (identified by * in Table 13). For further examination of the association of gender and insurance status with quality of care, logistic regressions were used to estimate each indicator separately for each age group, while controlling for potential confounding factors. A fixed reference group was used to assess group differences in quality of care. For example, males were the referent group for gender differences. Private insurance was the referent group for insurance status differences among midlife persons. Medicare and private insurance were the referent groups for insurance status differences among older adults. The multivariate analysis controlled for education, race/ethnicity, income and health status. Multivariate results were reported as adjusted odds ratios (OR) with 95 percent confidence intervals.

Because this analysis examined 17 simultaneous dependent variables, drawn from the same sample of diabetes patients, and 15 simultaneous dependent variables, drawn from the same sample of cardiovascular condition patients, a Bonferroni correction was used to interpret p-values. Thus, at the alpha testing level of 0.05, only p-values <0.002 (0.05/17) were considered significant for diabetes patients, and only p-values <0.003 (0.05/15) were considered significant for cardiovascular patients.

Table 11 shows the distribution of the key independent variables of interest among the study population. To facilitate the multivariate analyses, only persons with complete data on all analytic variables were included in the study sample (hence, the sample for this analysis differs from the previous analysis reported in Chapter 3.0, which did not include multivariate analyses). In the weighted study sample, the majority of diabetes and cardiovascular condition patients were midlife adults (54.4 percent diabetes, 55.5 percent cardiovascular conditions) and female (51.6 percent diabetes, 53.8 percent cardiovascular conditions). The majority of midlife adults with diabetes or cardiovascular conditions had some type of private health insurance (69.0 percent diabetes, 79.0 percent cardiovascular conditions), while approximately one in seven was uninsured (10.8 percent diabetes, 10.1 percent cardiovascular). Among older adults with Medicare, the majority also had some type of private health insurance (55.2 percent diabetes, 60.9 percent cardiovascular). Men were more likely to have private insurance than women. For example, in the midlife diabetes group, 73.7 percent of men had private insurance coverage (in combination with Medicare), compared to 48.2 percent of women.

Table 12 shows the distribution of individual covariates among the study sample. The majority of the study sample was non-Hispanic White (56.8 percent diabetes, 68.4 percent cardiovascular condition); had high school education or less; medium or high income; and was in excellent, very good or good health. Within each insurance strata, women were slightly more likely than men to report only high school education or less, income below or near the FPL and fair or poor health. For example, in the midlife diabetes group with private insurance coverage, 59.5 percent of women vs. 56.4 percent of men reported high school education or less; 22.3 percent of women vs. 18.2 percent of men reported income below or near the FPL; and 36.2 percent of women vs. 30.6 percent of men reported fair or poor health. These patterns were also seen among cardiovascular condition patients.

Quality of Care for Diabetes Patients

Table 13 gives the reported rates of receiving effectiveness of care services, delays in care (timeliness) and patient-centeredness in care for diabetes patients, stratified by age, insurance status and gender. Among midlife adults, receipt of services was less common among the uninsured compared to the privately or publicly insured, and within each group, similar proportions (within approximately 5 percentage points) of women and men reported receipt of services. There were slightly larger gender differences among uninsured or publicly insured midlife adults, but differences were in opposite directions, depending on the service. For example, a higher proportion of publicly insured midlife men than women (81.3 percent vs. 72.7 percent) reported having a foot examination, but a lower proportion of uninsured midlife men than women (57.1 percent vs. 66.7 percent) reported having a foot examination. Conversely, a lower proportion of publicly insured midlife men than women (47.2 percent vs. 58.2 percent) reported having an eye examination, but a higher proportion of uninsured midlife men than women (47.0 percent vs. 33.1 percent) reported having an eye examination. In the older age group, rates of receiving services were not greatly different between insurance or gender groups, although among both the privately insured (in combination with Medicare) and publicly insured, gender differences were larger (>5 percentage points) for receiving an influenza shot and the composite measure.

Among midlife adults, delays in care were less common among the privately insured compared to publicly insured or uninsured, and within each group, women were more likely to report delays. For example, among midlife adults with diabetes, the reported rate of delays in medical care was 6.2 percent for men vs. 10.9 percent for women with private insurance; the rates were 11.9 percent vs. 21.7 percent in the uninsured group for men and women, respectively. In contrast, the older age group reported fewer delays and the difference between gender and insurance groups was smaller, but women still reported more delays than men. 6.0 percent of men and 8.2 percent of women with Medicare and private insurance coverage reported delays in dental care, while among those with Medicare alone or with other public insurance, the rates were 5.7 percent for men and 10.5 percent for women. These patterns were consistent for each type of delay in the diabetes group, with the exception of delays in medical care for the privately insured (in combination with Medicare), where more men than women (5.3 percent vs. 3.8 percent) reported delays.

Small numbers limited comparison in the diabetes group for access to care for illness or injury. There were few gender and insurance differences for patient-centered indicators. Among midlife adults, 92.5 percent of men and 91.7 percent of women with private insurance reported that their provider explained things. These rates were 89.7 percent and 85.5 percent, respectively, for privately insured men and women. Among older adults, similar proportions (within 5 percentage points) also reported patient-centeredness in care, regardless of gender and insurance group.

Quality of Care for Cardiovascular Condition Patients

Table 13 also provides the reported rates of receiving effectiveness of care services, delays in care (timeliness) and patient-centeredness in care for cardiovascular condition patients, stratified by age, insurance status and gender. Among midlife adults, receipt of services was less common among the uninsured compared to the privately or publicly insured, and within each group there were no consistent gender differences, although uninsured women were more likely than men to report receipt of services. For example, a higher proportion of privately insured midlife men than women (69.4 percent vs. 66.6 percent) reported receiving dietary advice, but a lower proportion of uninsured midlife men than women (56.5 percent vs. 60.3 percent) reported receiving it. Conversely, a lower proportion of privately insured midlife men than women (68.3 percent vs. 71.8 percent) reported receiving exercise advice. Among the older age group, there were few gender or insurance differences in receipt of services.

Among midlife adults, delays in care were less common among the privately insured compared to publicly insured or uninsured. Women were more likely to report delays compared to men. For example, among midlife adults with cardiovascular conditions, the reported rate of delays in medical care was 4.7 percent for men vs. 7.6 percent for women with private insurance. These rates were 12.1 percent vs. 18.7 percent in the public insurance group and 19.5 percent vs. 27.4 percent in the uninsured group for men and women, respectively. In contrast, the older age group reported fewer delays in medical care. Differences between gender and insurance groups were smaller, with women reporting similar or only slightly higher rates of delays. For example, 3.5 percent of men and 3.4 percent of women with Medicare and private insurance coverage reported delays in medical care; rates were 3.9 percent for men and 5.4 percent for women with Medicare alone or other public insurance. These patterns were consistent for each type of delay in the diabetes groups.

Among persons 45–64 with cardiovascular conditions and private insurance who reported needing care for an illness or injury, 9.6 percent of men and 10.8 percent of women reported that they sometimes or never got care for an illness or injury as soon as they wanted. Problems in getting illness or injury care for persons with cardiovascular conditions were most common for the uninsured midlife group (30.7 percent for men and 31.6 percent for women) and least common for Medicare enrollees with private insurance (7.3 percent for men and 4.8 percent for women—the only comparison that favored women) or Medicare enrollees with public insurance only (6.5 percent for men

There were a few gender and insurance differences for patient-centered indicators. For example, rates of midlife adults who reported that their provider listens to them were 93 percent for men and 92.4 percent for women with private insurance vs. 88.5 percent for men and 85.7 percent for women with public insurance. Among older adults, similar proportions (within approximately 5 percentage points) of all adults also reported patient-centeredness in care, regardless of gender and insurance group, although rates were somewhat higher for provider listening and showing respect.

Regression Results for Diabetes Patients

With a few exceptions, adjusting for key patient factors did not greatly alter the patterns exhibited in the unadjusted associations for diabetes patients (Table 14). For effectiveness of care indicators among diabetes patients, and consistent with unadjusted results, uninsured midlife adults were less likely than the privately insured to report receipt of some services, with OR of 0.2 (95 percent CI, 0.1–0.4) for blood cholesterol testing to 0.5 (95 percent CI, 0.3–0.6) for eye examination, all p<0.002. There were no significant gender differences in receipt of services among midlife adults. Among older adults with Medicare coverage, there was no significant gender or insurance group difference in receipt of services.

Among diabetes patients, and consistent with unadjusted results, midlife women were about twice as likely as men to report delays in care. The odds ratios (OR) were 1.9 (95 percent CI, 1.4–2.5) for delays in care. Uninsured midlife adults were two to four times as likely to report delays in care as midlife adults with private insurance; for delays in medical care, the OR was 2.4 (95 percent CI, 1.4–4.0). Midlife adults with public insurance only were also about twice as likely to report a delay in at least one of the three types of care; for the composite measure, the OR was 1.9 (95 percent CI, 1.3–2.7). Among Medicare-insured older adults, gender differences were not significant in diabetes patients.

Patterns exhibited for patient-centeredness indicators among diabetes patients remained after adjusting for sociodemographic factors. Midlife uninsured adults were about half as likely as the privately insured to report high quality on the patient-centered care composite (OR 0.5, 95 percent CI, 0.3–0.7, p<0.002). However, there were no other significant insurance group or gender differences among both midlife and older adults in receipt of patient-centered care.

Regression Results for Cardiovascular Condition Patients

With a few exceptions, adjusting for key patient factors did not greatly alter the patterns exhibited in unadjusted associations for cardiovascular condition patients (Table 15). For effectiveness of care indicators among cardiovascular patients and consistent with unadjusted results, uninsured midlife adults were significantly less likely than the privately insured to receive almost all services, with odds ratios ranging from 0.3 (95 percent CI, 0.2–0.4) for blood cholesterol testing to OR 0.7 (95 percent CI, 0.6–0.8) for dietary advice, all p<0.003. There were no significant differences in receipt of services between publicly and privately insured midlife adults. However, midlife women were more likely than men to receive some services (with odds ranging from 21 percent higher for exercise advice to 67 percent higher for blood pressure testing, all p<0.003). Among older adults with Medicare coverage, there was no significant gender or insurance group difference in receipt of services.

Among diabetes patients and consistent with unadjusted results, midlife women were about twice as likely as men to report delays in care. For example, the odds ratios were 1.7 (95 percent CI, 1.5–1.9) for delay in care among the cardiovascular condition group. Uninsured midlife adults were two to four times as likely to report delays in care as midlife adults with private insurance; for delays in medical care, the OR was 4.0 (95 percent CI, 3.1–5.2) among the cardiovascular condition group. Midlife adults with public insurance only were also about twice as likely to report a delay in at least one of the three types of care; the OR was 1.7 (95 percent CI, 1.4–2.1) among cardiovascular condition groups.

Among Medicare-insured older adults, gender differences were of smaller magnitude and were significant only in the cardiovascular group, with women being more likely to report any one of the three delays in care (OR, 1.3; 95 percent CI, 1.2–1.6). There were no significant differences in delays in care between Medicare-insured older adults with private or public insurance, but uninsured midlife individuals with cardiovascular conditions were more likely to report being unable to get care for illness or injury (OR, 3.0; 95 percent CI, 2.2–4.2).

For patient-centeredness indicators among cardiovascular condition patients, patterns from unadjusted associations remained after adjustment. Uninsured midlife adults were less likely than the privately insured to report most aspects of patient-centered care, with odds ratios ranging from 0.4 (95 percent CI, 0.3–0.5) for the composite measure, to 0.6 (95 percent CI, 0.5–0.8) for their provider spending enough time with them (all p<0.003), but there were no significant differences between publicly and privately insured midlife adults. Among older adults, there were no significant insurance group differences. There were only a few significant gender differences among both midlife and older adults, and those were in opposite directions.

The analysis sought to describe the relationship between health insurance coverage and the quality of care that men and women experience. The most significant, consistent findings were related to access to care. For the most part, women were significantly more likely than men to report delays in care. Differences were exhibited among midlife adults who reported having diabetes or cardiovascular conditions. While gender disparities did not attain statistical significance among Medicare-insured older adults with diabetes, a few significant disparities persisted among older adults with cardiovascular conditions. Findings are consistent with prior research showing that women in midlife have more problems in accessing care, compared to men in the same period of life (Rustgi et al 2009). Attainment of Medicare-eligibility among older adults appears to reduce, but not eliminate, gender disparities in delays in care.

Analysis also demonstrated significant differences in access to care based on insurance coverage. Among midlife adults, uninsured individuals were more likely to report delays in care than other health insurance status groups. There were also some significant differences in access to care between those with private insurance vs. public insurance. However, among older adults, there were no significant differences in delays in care based on type of insurance, and the rates of reported delays were much lower than those reported by midlife adults. These patterns suggest the importance of Medicare in providing access to care for older adults, and speak to the larger issue of significant delays in care for midlife adults in the absence of health coverage provided by Medicare or other publicly supported health insurance programs. Prior research differs on whether obtaining Medicare coverage is associated with general improvement in health status, but indicates that the impact of health insurance may be more profound for persons with cardiovascular conditions or diabetes (McWilliams et al 2007a, 2007b; Polsky et al 2009).

Guidelines for cardiovascular conditions and diabetes recommend ongoing monitoring services and treatment (American Heart Association 2008; National Institute of Diabetes and Digestive and Kidney Diseases 2009). Delays in receipt of medical services and prescription drugs could lead to suboptimal quality and outcomes. Differences in access to care based on type of insurance coverage are well documented. Compared to men, women have lower incomes to meet rising health care costs, have higher rates of chronic conditions, use more health care services and rely more on public programs and insurance obtained through their spouses (Glied et al., 2008; Patchias and Waxman, 2007; Rustgi et al., 2009). It is unclear whether differences in self-reports about delays in care reflect women's greater propensity to self-identify the need for care, or greater difficulty in obtaining needed care. A recent study indicated that a spouse's transition to Medicare contributed to women's inability to gain access to care, despite having consistent insurance coverage (Schumacher et al 2009). Findings from this study suggest that more research is needed to understand better how women's unique health care needs and insurance coverage experiences affect

For the remaining quality of care indicators, there were few statistically significant gender or insurance group differences in effectiveness of care or patient-centeredness of care, and differences did not consistently favor women or men, or any insurance group.

Limitations

There are several limitations to this analysis. First is the reliance on self-reported disease status to identify older adults with diabetes and cardiovascular conditions. There is the possibility of misclassification, as some individuals who self-identify as having these conditions may not actually have them. In particular, those with diabetes may not meet the clinical definition of the disease. However, there is evidence that older adults can reliably report their chronic conditions, and positive predictive value of such reports is high (Miller et al 2008; Silliman and Lash 1999).

Second, while analysis explicitly adjusts for several key individual factors—including patient self-rated health status, race/ethnicity, education and income—it does not adjust for other factors that may influence quality of care, such as patient values and care preferences, presence of comorbid conditions and geographic region. Third, even after combining three years of MEPS data, sample size limitations prevented the exploration of how disparities affect particular subgroups of men and women (e.g., Black men and women, or men and women with less education). Fourth, because of the confounding of age and Medicare coverage, we cannot rule out the possibility of the role of age in the results. Despite these limitations, analysis provides nationally representative data on gender-based and health insurance-based disparities among older adults with diabetes and