Disparities in Quality of Care for Midlife Adults (Ages 45–64) Versus Older Adults (Ages >65). 4.3 Results

05/01/2012

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.

View full report

Preview
Download

"report.pdf" (pdf, 548.24Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®