Effects of Race and Income on Mortality and Use of Services among Medicare Beneficiaries
Marian E. Gornick, M.S., Paul W. Eggers, Ph.D., Thomas W. Reilly, Ph.D., Renee M. Mentnech, M.S., Leslye K. Fitterman, Ph.D., Lawrence E. Kucken, M.P.A., and Bruce C. Vladeck, Ph.D.
Background There are wide disparities between blacks and whitesin the use of many Medicare services. We studied the effectsof race and income on mortality and use of services.
Methods We linked 1990 census data on median income accordingto ZIP Code with 1993 Medicare administrative data for 26.3million beneficiaries 65 years of age or older (24.2 millionwhites and 2.1 million blacks). We calculated age-adjusted mortalityrates and age- and sex-adjusted rates of various diagnoses andprocedures according to race and income and computed black:whiteratios. The 1993 Medicare Current Beneficiary Survey was usedto validate the results and determine rates of immunizationagainst influenza.
Results For mortality, the black:white ratios were 1.19 formen and 1.16 for women (P<0.001 for both). For hospital discharges,the ratio was 1.14 (P<0.001), and for visits to physiciansfor ambulatory care it was 0.89 (P<0.001). For every 100women, there were 26.0 mammograms among whites and 17.1 mammogramsamong blacks. As compared with mammography rates in the respectivemost affluent group, rates in the least affluent group were33 percent lower among whites and 22 percent lower among blacks.The black:white rate ratio was 2.45 for bilateral orchiectomyand 3.64 for amputations of all or part of the lower limb (P<0.001for both). For every 1000 beneficiaries, there were 515 influenzaimmunizations among whites and 313 among blacks. As comparedwith immunization rates in the respective most affluent group,rates in the least affluent group were 26 percent lower amongwhites and 39 percent lower among blacks. Adjusting the mortalityand utilization rates for differences in income generally reducedthe racial differences, but the effect was relatively small.
Conclusions Race and income have substantial effects on mortalityand use of services among Medicare beneficiaries. Medicare coveragealone is not sufficient to promote effective patterns of useby all beneficiaries.
Studies of the use of services in the first two decades of theMedicare program showed that racial disparities were disappearingwith regard to overall measures, such as rates of visits tophysicians and hospital discharges.1,2,3 In 1967, the firstfull year of Medicare, the hospital-discharge rate was 29 percentlower among minority beneficiaries (most of whom were black)than among white beneficiaries; by 1987, the rate among blackswas 4 percent higher than among whites.4,5 More recent analyses,however, show wide racial disparities in the use of many medicaland surgical services.5,6,7,8,9,10,11,12,13,14 Such disparitieshave also been found in other groups in the United States.15,16,17,18
Medicare data on hospital discharges among persons 65 yearsof age or older show that from 1986 to 1992, black beneficiariesused 17 common procedures less often than white beneficiaries;among the procedures, coronary-artery bypass surgery, percutaneoustransluminal coronary angioplasty, and total hip replacementwere less than half as frequent among blacks.5 The data indicate,however, that certain other, less common, surgical procedureswere performed more frequently among blacks. For example, amputationof all or part of the lower limb was 3.6 times as frequent amongblacks. In 62 percent of amputations, the principal diagnosiswas diabetes mellitus. Diabetes is only 1.7 times as prevalentin elderly black persons as in whites,19 however, which suggeststhat the difference in the rates of amputation of all or partof the lower limb is not entirely explained by the differencein the prevalence of diabetes. Similarly, bilateral orchiectomywas 2.2 times as frequent among black men as among whites; in90 percent of these cases, the principal diagnosis was prostatecancer.5 Although the rate of prostate cancer among the elderlyis only 1.3 times as high in black men as in white men,20 bilateralorchiectomy is performed primarily to treat metastatic prostatecancer,21 and data from the Surveillance, Epidemiology, andEnd Results program show that at the time of diagnosis, blackmen had 2.2 times the rate of metastatic prostate cancer foundin white men,20 a racial difference similar to that in the caseof bilateral orchiectomy.
These variations in patterns of utilization raise questionsabout the factors contributing to such racial differences. Often,studies designed to analyze the use of services among subgroupsof a population use race partly as a surrogate for socioeconomicstatus.22,23 Although it is better to study the effects of socioeconomicstatus directly, information on variables such as income andeducation is not available in many data bases, including theadministrative files of the Medicare program.
To analyze the effects of race and socioeconomic status, weused data from the U.S. Census as a surrogate for informationon household income. We addressed two questions. First, howdo race and income affect mortality and the use of servicescovered by Medicare? Second, how much do racial differencesdiminish when the rates are standardized according to income?
Methods
We linked data from the U.S. Census on median household incomesaccording to ZIP Code with administrative data on individualenrollees in the Medicare program. Our approach was based onstudies that have validated the use of aggregate informationon socioeconomic status obtained from the census as a proxyfor data on the socioeconomic status of individuals, with thecaveat that the aggregate data reflect both the characteristicsof the individuals and those of the areas where the individualslive.24,25,26,27 To examine possible biases in our approach,we compared analyses of income effects derived from aggregatedata with analyses of income effects derived from individualsurvey data.
Medicare Data
The 1993 file of Medicare enrollment (containing informationon age, sex, race, ZIP Code of residence, and date of death,as applicable) was used to generate a file of all white andblack enrollees 65 years of age or older. We excluded 2.4 millionenrollees in health maintenance organizations for whom dataon the use of services were unavailable and 1.9 million enrolleeswho belonged to other races or for whom information on racewas missing from the file. This selection process yielded 27.5million enrollees (25.3 million whites and 2.2 million blacks).
The 1993 files for Medicare Part A, containing information onall hospitalizations, were used as a source of data on hospitaldischarges. About 25 percent of beneficiaries had at least 1hospital stay in 1993, for a total of approximately 9 millionstays. The 1993 Part B claims files were used as a source ofdata on all services rendered by physicians. About 90 percentof beneficiaries visited a physician at least once in 1993,for a total of approximately 200 million visits.
Census Data
We used income data from the 1990 U.S. Census, which was reportedaccording to age, racial group, and various geographic configurations.Median household incomes of persons 65 years of age or olderwere calculated separately for whites and blacks, accordingto ZIP Code.
Linkage of Medicare Data and Census Data
We attempted to match the ZIP Codes of residence of the 27.5million Medicare beneficiaries with the ZIP Codes in the censusfile. For 26.3 million beneficiaries, the linkage was successful.It was incomplete for 4 percent of white beneficiaries and 6percent of blacks because of unmatched ZIP Codes or missingdata on income in the census file; these beneficiaries wereexcluded from further analysis. We then assigned a proxy incometo each beneficiary that corresponded to the median householdincome for his or her race and ZIP Code. White and black beneficiarieswere then combined and assigned to four groups (of approximatelyequal size) according to income: $13,100 or below; $13,101 to$16,300; $16,301 to $20,500, and $20,501 or above.
Statistical Analysis
The rates of use of services calculated according to race andincome group were adjusted for age and sex to the overall Medicarepopulation. Mortality rates were adjusted for age. Ratios ofthe rates among blacks to the rates among whites were computed.After further adjustment of rates for income, new ratios werecomputed. Within each racial group, ratios were also computedfor each income group, with the group with the highest incomeserving as the reference group. Standard errors of the rateratios were estimated by a Taylor series approximation for theratio of two random variables. To assess the statistical significanceof the rate ratios, z-tests were used. The critical values fordetermining statistical significance were adjusted upward toallow for multiplicity among the tests. Because the tests werebased on very large samples (ranging from 6.7 million beneficiariesin the highest-income group of whites to 128,000 beneficiariesin the highest-income group of blacks), the standard errorswere very small, making most differences statistically significant.Rate ratios and P values are presented. Standard errors notincluded in the paper are available from the authors on request.
We analyzed utilization rates for the following four sets ofservices: first, two global measures (all visits to physiciansfor ambulatory care and all hospital discharges); second, hospitalizationsfor ischemic heart disease, coronary-artery bypass surgery,and percutaneous transluminal coronary angioplasty; third, mammography(an elective service) and hip-fracture repair (a nonelectiveservice); and fourth, amputation of all or part of the lowerlimb and bilateral orchiectomy. Screening mammography becamea benefit covered by Medicare on January 1, 1991. Mammographyrates include both screening and diagnostic mammography, becausethe codes used in billing Medicare were not used uniformly byall providers.
Weighted least-squares multiple regression analyses were performedwith the ZIP Code area as the unit of analysis. Models accountingfor rates of utilization were estimated separately for blacksand whites; in each model, the focal independent variable wasthe race-specific median income of residents of the ZIP Codearea, with the percentage of people 75 years of age or olderand the percentage of women included as covariates. A combinedmodel was also estimated that included the same variables asthe race-specific models, as well as the percentage of blacksin the ZIP Code area and an interaction term for race and income.
Validation
We performed analyses similar to those described above withpersonal (individual and spousal) income as reported in thenationwide Medicare Current Beneficiary Survey28 and comparedthe results with those of the analyses of utilization accordingto median income in the ZIP Code. The Medicare Current BeneficiarySurvey, which included nearly 9000 enrollees 65 years of ageor older who were not enrolled in health maintenance organizationsin 1993, used a sample large enough that rates of utilizationof the following three services included in the ZIP Code analysescould be studied according to race and income: visits to physiciansfor ambulatory care, hospitalization (as reflected by the totalnumber of hospital discharges), and mammography.
Immunizations against influenza were not included in the majoranalyses because they were underreported in the Medicare administrativedata. Because such immunizations can serve as a model of theuse of preventive services that do not require coinsurance,we did include them in the analyses based on the Medicare CurrentBeneficiary Survey. Medicare reimbursement for immunizationsagainst influenza was initiated on May 1, 1993; nearly all suchimmunizations are given in the fall. The rates of mammographyand immunization were based on the use reported by the beneficiaries,and rates of visits to physicians and hospitalizations werebased on claims data.
Results
The distributions of age and sex were similar among the 24.2million white and the 2.1 million black beneficiaries studied(Table 1). The white beneficiaries were distributed fairly evenlyamong the income groups, but the black beneficiaries were veryunevenly distributed, with only 6 percent of blacks in the highest-incomegroup and 73 percent in the lowest-income group.
Table 1. Medicare Beneficiaries in the Study According to Age, Sex, and Race, 1993.
Figure 1 shows mortality rates in 1993 for the Medicare beneficiariesaccording to sex, race, and income group. The overall age-adjustedmortality rate was higher for black men (8.0 per 100) than forwhite men (6.7 per 100), resulting in a black:white mortalityratio of 1.19 (P<0.001). The corresponding mortality ratesfor black women (5.2 per 100) and white women (4.5 per 100)resulted in a black:white mortality ratio of 1.16 (P<0.001).
Figure 1. Mortality Rates According to Race, Sex, and Income among Medicare Beneficiaries 65 or Older, 1993.
Rates are adjusted for age to the total Medicare population. Data were derived from the linked 1993 Medicare files and 1990 U.S. Census information.
In each of the subgroups defined by sex and race except blackwomen, the highest-income group had the lowest mortality ratesand the lowest-income group had the highest mortality rates.The greatest disparity in mortality was found among white men,a difference of 19 percent between the highest and the lowestgroups (P<0.001).
In 1993, black Medicare beneficiaries made 7.2 visits per personto physicians for ambulatory care, as compared with 8.1 visitsper person among whites, for a black:white ratio of 0.89 (P<0.001)(Figure 2A and Figure 2B). In contrast, black beneficiarieshad 376 hospital discharges per 1000 persons, 14 percent higherthan the rate of 329 among whites (P<0.001).
Figure 3. Rates of Hospitalization for Ischemic Heart Disease (Panel A) and of Percutaneous Transluminal Coronary Angioplasty (Panel B) and Coronary-Artery Bypass Surgery (Panel C), According to Race and Income among Medicare Beneficiaries 65 or Older, 1993.
Rates are adjusted for age and sex to the total Medicare population. Data were derived from the linked 1993 Medicare files and 1990 U.S. Census information.
The least affluent white beneficiaries visited physicians forambulatory care 18 percent less often than the most affluentwhites (7.3 vs. 9.0 visits, P<0.001) and were dischargedfrom the hospital 24 percent more often than the most affluent(369.6 vs. 296.9 discharges, P<0.001). Among the black beneficiaries,the income-related patterns were not as marked. The lowest-incomegroup had fewer visits for ambulatory care per person than thehighest-income group (7.1 vs. 8.0, P<0.001) but the hospitalizationrates were similar.
White enrollees had 33.8 discharges for ischemic heart diseaseper 1000 in 1993, as compared with 25.0 per 1000 among blacks(Figure 3A, Figure 3B, and Figure 3C), resulting in a black:whiteratio of 0.74 (P<0.001). Rates for both percutaneous transluminalcoronary angioplasty and coronary-artery bypass surgery weresubstantially higher among white beneficiaries: 5.4 and 4.8procedures, respectively, were performed per 1000 white persons,as compared with 2.5 and 1.9 per 1000 black persons. Thus, theblack:white ratio was 0.46 for percutaneous transluminal coronaryangioplasty and 0.40 for coronary-artery bypass surgery (P<0.001for both) (Figure 3A, Figure 3B, and Figure 3C).
For these cardiac-related services, income patterns differedaccording to race. Among the white beneficiaries, the leastaffluent were hospitalized for ischemic heart disease 28 percentmore often than the most affluent (P<0.001); there was nosimilar difference in the rates of either revascularizationprocedure studied (Figure 3A, Figure 3B, and Figure 3C). Amongblack beneficiaries, the least affluent were hospitalized forischemic heart disease 13 percent less often than the most affluent(P<0.001). The least affluent had an angioplasty rate lowerby 24 percent (P<0.001) and a rate of coronary-artery bypasssurgery lower by 16 percent (P = 0.01) than the most affluent(Figure 3A, Figure 3B, and Figure 3C).
The use of mammography in 1993 varied substantially accordingto race and income (Figure 4A and Figure 4B). For every 100women, there were 26.0 mammograms among whites and 17.1 mammogramsamong blacks, for a black:white ratio of 0.66 (P<0.001).Income had a substantial effect among women of both races; inwhites, the mammography rate among the least affluent womenwas 33 percent lower than among the most affluent (P<0.001),and in blacks the rate was 22 percent lower among the leastaffluent than among the most affluent (P<0.001).
Overall, the rate of reduction of fracture of the femur washigher among white women (7.0 per 1000) than among black women(2.9 per 1000), for a black:white ratio of 0.42 (P<0.001).Unlike mammography rates, hip-repair rates differed only slightlyamong income groups.
The rates of amputation of all or part of the lower limb in1993 were 6.7 per 1000 among black beneficiaries and 1.9 per1000 among white beneficiaries, for a black:white ratio of 3.64(P<0.001) (Figure 5A and Figure 5B). The rates of bilateralorchiectomy were 2.0 per 1000 black men and 0.8 per 1000 whitemen, for a black:white ratio of 2.45 (P<0.001) (Figure 5Aand Figure 5B). Among white beneficiaries, income had a significanteffect on the use of both these procedures. The lowest-incomegroup had an amputation rate 51 percent higher than that ofthe highest-income group (P<0.001), and among white men,the lowest-income group had a rate of bilateral orchiectomy43 percent higher than that of the highest-income group (P<0.001)(Figure 5A and Figure 5B). Among black beneficiaries, ratesof bilateral orchiectomy were not associated with income, butblack beneficiaries in the lowest-income group had a rate ofamputation of all or part of the lower limb that was 20 percenthigher than that of the highest-income group (P<0.001) (Figure 5Aand Figure 5B).
Adjustment for Income
Adjusting the rates of mortality and use of services among blacksand whites for differences in income affected the black:whiteratios relatively little, although generally such adjustmentreduced the differences between races (Table 2). The black:whitemortality ratio for men declined from 1.19 to 1.16 after adjustmentfor income; for women, the ratio remained at 1.16.
Table 2. Effect of Adjustment for Income on Differences between Blacks and Whites in Mortality and Use of Services.
After this adjustment, the black:white ratios for percutaneoustransluminal coronary angioplasty (0.46) and coronary-arterybypass surgery (0.40) increased to 0.51 and 0.43, respectively.The greatest effects of the adjustment for income were in thecase of mammography, for which the black:white ratio increasedfrom 0.66 to 0.75, and for visits to physicians for ambulatorycare, for which the ratio increased from 0.89 to 0.93. The resultsof the multiple regression analyses were consistent with theresults of the descriptive analyses (data not shown).
Comparison of the Medicare Current Beneficiary Survey Analyses with the Zip Code Analyses
The 1993 Medicare Current Beneficiary Survey contained informationon income for 845 black and 7911 white beneficiaries 65 yearsof age or older. For the white beneficiaries, the analyses ofthe effects of individual incomes generally validated the analysesof the effects of income according to ZIP Code. In the survey,the overall hospital-discharge rate for the least affluent whitebeneficiaries was 55 percent higher than the rate for the mostaffluent (rate ratio [±SE], 1.55±0.115; P<0.001),and the mammography rate for the least affluent white womenwas 53 percent lower than the rate for the most affluent women(rate ratio , 0.47± 0.028; P<0.001). These effectsof income in the Medicare Current Beneficiary Survey were inthe same direction as those in the ZIP Code analyses but weremore pronounced, indicating that the effect of income on ratesof hospitalization and mammography among white beneficiariesmay be underestimated in analyses according to ZIP Code medianincome. The one exception was for visits to physicians for ambulatorycare; for that variable, the Medicare Current Beneficiary Surveyshowed no effect of income, whereas the analysis according toZIP Code income showed a moderate effect.
For the black beneficiaries, the income-related patterns inthe Medicare Current Beneficiary Survey were more variable thanthey were for white beneficiaries, as we found in the analysesaccording to ZIP Code income. However, among the least affluentblack women the mammography rate was 39 percent lower than itwas among the most affluent black women (rate ratio, 0.61±0.134;P = 0.011), which was again a more pronounced difference thanwas found in the analyses according to ZIP Code income.
The Medicare Current Beneficiary Survey showed 515 immunizationsagainst influenza per 1000 white beneficiaries and 313 immunizationsper 1000 blacks, for a black:white ratio of 0.61±0.048(P<0.001). Among both whites and blacks, there was a notableeffect of income on these rates. The immunization rate amongthe least affluent white beneficiaries was 26 percent lowerthan it was among the most affluent (rate ratio, 0.74±0.024;P<0.001), and among the least affluent black beneficiariesit was 39 percent lower than among the most affluent (rate ratio,0.61±0.100; P<0.001).
Discussion
By linking census data on median incomes with Medicare administrativedata, we were able to discern racial and income patterns forservices with rates too low to be analyzed with existing surveydata. The effects of income in the analyses based on medianincomes were generally smaller than in those based on individualincomes, indicating that our approach provides information onthe overall direction of the effect of income but may underestimateits magnitude.
Comparing the patterns of use of several types of services helpsin drawing inferences that may not be apparent from analyzingthe use of individual services. Black beneficiaries and low-incomebeneficiaries (white and black) have fewer visits to physiciansfor ambulatory care, fewer mammograms, and fewer immunizationsagainst influenza but are hospitalized more often and have highermortality rates (as is consistent with the relation betweenincome and mortality in the U.S. population 25 to 64 years ofage).30 These patterns suggest that these two groups of beneficiariesmay be receiving less primary and preventive care than eitherwhite or more affluent beneficiaries. In addition, blacks andlower-income white beneficiaries have higher rates of amputationof all or part of the lower limb and bilateral orchiectomy.This suggests that these groups of beneficiaries are at higherrisk for procedures associated with less than optimal managementof chronic diseases.5 The differences in these patterns accordingto race and income may reflect a multitude of factors, includingeducational, cultural, and behavioral variables; individualpreferences; differences in the treatment of disease, such asthe use of hormonal therapy for prostate cancer; differencesin supplementary insurance8; and the availability of services.The racial differences in amputations of all or part of thelower limb are consistent with those found in a study of Medicarebeneficiaries who underwent surgery for peripheral vasculardisease,31 which showed that black beneficiaries were less likelythan white beneficiaries to have leg-sparing surgery and morelikely to undergo amputation.
We found that repair of a hip fracture was 2.4 times as frequentamong white women as among black women, a figure consistentwith data from the National Health and Nutrition ExaminationSurvey that showed osteoporosis in the neck of the femur tobe 2.4 times as frequent in white women as in black women 50years of age or older.32 In our study there were only smalland inconsistent effects of income on rates of hip-fracturerepair, a finding that suggests that race and socioeconomicstatus may not play an important part in access to nonelectiveservices for elderly people enrolled in Medicare.
The lack of information about the health status of individualsand the underlying medical conditions of the beneficiaries limitsour ability to explore in greater depth the appropriatenessof patterns of use of coronary revascularization procedures.However, our analyses showed that the poorest white beneficiarieshad the highest rate of hospitalization for ischemic heart disease,without correspondingly higher rates of percutaneous transluminalcoronary angioplasty and coronary-artery bypass surgery. Thisfinding and the lower rate of use of many common surgical proceduresamong black beneficiaries suggest that there may be barriersto elective surgical procedures for some groups of beneficiaries.
The implementation of Medicare was necessary to provide accessto care for the elderly. However, the differential patternsin the use of many specific services according to race and incomeindicate that the provision of health insurance alone does notsuffice to promote effective patterns of use by all beneficiaries.
Figure 4. Rates of Mammography (Panel A) and Hip-Fracture Repair (Panel B) According to Race and Income among Female Medicare Beneficiaries 65 or Older, 1993.
Rates are adjusted for age to the total female Medicare population. Data were derived from the linked 1993 Medicare files and 1990 U.S. Census information. Mammography rates include both screening and diagnostic mammography, because the mammography codes used in billing Medicare were not used uniformly by all providers.
Figure 5. Rates of Amputation of All or Part of the Lower Limb (Panel A) and Bilateral Orchiectomy (Panel B), Two Procedures Performed More Frequently in Black Beneficiaries Than in Whites, According to Race and Income among Medicare Beneficiaries 65 or Older, 1993.
Amputation rates are adjusted for age and sex to the total Medicare population; rates of bilateral orchiectomy are adjusted for age to the total male Medicare population. Data were derived from the linked 1993 Medicare files and 1990 U.S. Census information.
Figure 2. Rates of Visits to Physicians for Ambulatory Care (Panel A) and Hospital-Discharge Rates (Panel B), According to Race and Income among Medicare Beneficiaries 65 or Older, 1993.
Rates are adjusted for age and sex to the total Medicare population. Data were derived from the linked 1993 Medicare files and 1990 U.S. Census information.
We are indebted to A. Marshall McBean of the University of MinnesotaSchool of Public Health for assistance in the use of 1990 U.S.Census data, to Rosemarie Hakim and James D. Lubitz for helpfulreview and comments, and to Cheryl Hickman for assistance inthe preparation of the manuscript.
Source Information
From the Health Care Financing Administration, Department of Health and Human Services, Baltimore. The opinions expressed in this paper are those of the authors and do not necessarily reflect those of the Health Care Financing Administration.
Address reprint requests to Ms. Gornick at the Health Care Financing Administration, Office of Research and Demonstrations, 7500 Security Blvd., C-3-24-07, Baltimore, MD 21244-1850.
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(2008). Racial Disparities in Health Care Access and Cardiovascular Disease Indicators in Black and White Older Adults in the Health ABC Study. J Aging Health
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Gornick, M. E.
(2008). A Decade of Research on Disparities in Medicare Utilization: Lessons for the Health and Health Care of Vulnerable Men. AJPH
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Sequist, T. D., Fitzmaurice, G. M., Marshall, R., Shaykevich, S., Safran, D. G., Ayanian, J. Z.
(2008). Physician Performance and Racial Disparities in Diabetes Mellitus Care. Arch Intern Med
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Williams, B. A., Lindquist, K., Sudore, R. L., Covinsky, K. E., Walter, L. C.
(2008). Screening Mammography in Older Women: Effect of Wealth and Prognosis. Arch Intern Med
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Kokkinos, P., Myers, J., Kokkinos, J. P., Pittaras, A., Narayan, P., Manolis, A., Karasik, P., Greenberg, M., Papademetriou, V., Singh, S.
(2008). Exercise Capacity and Mortality in Black and White Men. Circulation
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Trivedi, A. N., Rakowski, W., Ayanian, J. Z.
(2008). Effect of Cost Sharing on Screening Mammography in Medicare Health Plans. NEJM
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Bernheim, S. M., Ross, J. S., Krumholz, H. M., Bradley, E. H.
(2008). Influence of Patients' Socioeconomic Status on Clinical Management Decisions: A Qualitative Study. Ann Fam Med
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Cukor, D., Cohen, S. D., Peterson, R. A., Kimmel, P. L.
(2007). Psychosocial Aspects of Chronic Disease: ESRD as a Paradigmatic Illness. J. Am. Soc. Nephrol.
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Smith, W. R., Betancourt, J. R., Wynia, M. K., Bussey-Jones, J., Stone, V. E., Phillips, C. O., Fernandez, A., Jacobs, E., Bowles, J.
(2007). Recommendations for Teaching about Racial and Ethnic Disparities in Health and Health Care. ANN INTERN MED
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Tucker, C. M., Ferdinand, L. A., Mirsu-Paun, A., Herman, K. C., Delgado-Romero, E., van den Berg, J. J., Jones, J. D.
(2007). The Roles of Counseling Psychologists in Reducing Health Disparities. The Counseling Psychologist
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Williams, R. A.
(2007). Cultural Diversity, Health Care Disparities, and Cultural Competency in American Medicine. J Am Acad Orthop Surg
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White, A. A. III, Hoffman, H. L.
(2007). Culturally Competent Care Education: Overview and Perspectives. J Am Acad Orthop Surg
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(2007). Environmental influences on the high mortality from colorectal cancer in African Americans. Postgrad. Med. J.
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Wamala, S., Merlo, J., Bostrom, G., Hogstedt, C.
(2007). Perceived discrimination, socioeconomic disadvantage and refraining from seeking medical treatment in Sweden. J. Epidemiol. Community Health
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Sherkat, D. E., Kilbourne, B. S., Cain, V. A., Hull, P. C., Levine, R. S., Husaini, B. A.
(2007). The Impact of Health Service Use on Racial Differences in Mortality among the Elderly. Research on Aging
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Ferraro, K. F., Thorpe, R. J. Jr, McCabe, G. P., Kelley-Moore, J. A., Jiang, Z.
(2006). The color of hospitalization over the adult life course: cumulative disadvantage in black and white?. Journals of Gerontology Series B: Psychological Sciences and Social Science
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Neufeld, S., Lysack, C.
(2006). Investigating Differences Among Older Adults' Access to Specialized Rehabilitation Services. J Aging Health
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Yu, W., Wagner, T. H., Barnett, P. G.
(2006). Determinants of Cost among People Who Died in VA Nursing Homes. Med Care Res Rev
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Scheppers, E., van Dongen, E., Dekker, J., Geertzen, J., Dekker, J.
(2006). Potential barriers to the use of health services among ethnic minorities: a review. Fam Pract
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Pearson, S.-A., Soumerai, S., Mah, C., Zhang, F., Simoni-Wastila, L., Salzman, C., Cosler, L. E., Fanning, T., Gallagher, P., Ross-Degnan, D.
(2006). Racial disparities in access after regulatory surveillance of benzodiazepines.. Arch Intern Med
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Goldfarb-Rumyantzev, A. S., Koford, J. K., Baird, B. C., Chelamcharla, M., Habib, A. N., Wang, B.-J., Lin, S.-j., Shihab, F., Isaacs, R. B.
(2006). Role of Socioeconomic Status in Kidney Transplant Outcome. CJASN
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Stone, D.
(2006). Reframing the Racial Disparities Issue for State Governments. Journal of Health Politics, Policy and Law
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Lucas, F.L., DeLorenzo, M. A., Siewers, A. E., Wennberg, D. E.
(2006). Temporal Trends in the Utilization of Diagnostic Testing and Treatments for Cardiovascular Disease in the United States, 1993-2001. Circulation
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Trivedi, A. N., Sequist, T. D., Ayanian, J. Z.
(2006). Impact of Hospital Volume on Racial Disparities in Cardiovascular Procedure Mortality. J Am Coll Cardiol
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Ostermann, J., Sloan, F. A., Herndon, L., Lee, P. P.
(2005). Racial Differences in Glaucoma Care: The Longitudinal Pattern of Care. Arch Ophthalmol
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Brenner, M H.
(2005). Commentary: Economic growth is the basis of mortality rate decline in the 20th century--experience of the United States 1901-2000. Int J Epidemiol
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Skinner, J., Chandra, A., Staiger, D., Lee, J., McClellan, M.
(2005). Mortality After Acute Myocardial Infarction in Hospitals That Disproportionately Treat Black Patients. Circulation
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Bynum, J. P. W., Braunstein, J. B., Sharkey, P., Haddad, K., Wu, A. W.
(2005). The Influence of Health Status, Age, and Race on Screening Mammography in Elderly Women. Arch Intern Med
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Slater, J. S., Henly, G. A., Ha, C. N., Malone, M. E., Nyman, J. A., Diaz, S., McGovern, P. G.
(2005). Effect of Direct Mail as a Population-Based Strategy to Increase Mammography Use among Low-Income Underinsured Women Ages 40 to 64 Years. Cancer Epidemiol. Biomarkers Prev.
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Baldwin, L.-M., Dobie, S. A., Billingsley, K., Cai, Y., Wright, G. E., Dominitz, J. A., Barlow, W., Warren, J. L., Taplin, S. H.
(2005). Explaining Black-White Differences in Receipt of Recommended Colon Cancer Treatment. JNCI J Natl Cancer Inst
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Niefeld, M. R., Kasper, J. D.
(2005). Access to Ambulatory Medical and Long-Term Care Services Among Elderly Medicare and Medicaid Beneficiaries: Organizational, Financial, and Geographic Barriers. Med Care Res Rev
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O'Neill, L., Kuder, J.
(2005). Explaining Variation in Physician Practice Patterns and Their Propensities to Recommend Services. Med Care Res Rev
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Freburger, J. K, Holmes, G. M
(2005). Physical Therapy Use by Community-Based Older People. ptjournal
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Fitzpatrick, A. L., Powe, N. R., Cooper, L. S., Ives, D. G., Robbins, J. A.
(2004). Barriers to Health Care Access Among the Elderly and Who Perceives Them. AJPH
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Escarce, J. J., McGuire, T. G.
(2004). Changes in Racial Differences in Use of Medical Procedures and Diagnostic Tests Among Elderly Persons: 1986-1997. AJPH
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Bach, P. B., Pham, H. H., Schrag, D., Tate, R. C., Hargraves, J. L.
(2004). Primary Care Physicians Who Treat Blacks and Whites. NEJM
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Castro, L., Yolton, K., Haberman, B., Roberto, N., Hansen, N. I., Ambalavanan, N., Vohr, B. R., Donovan, E. F.
(2004). Bias in Reported Neurodevelopmental Outcomes Among Extremely Low Birth Weight Survivors. Pediatrics
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Rothenberg, B. M., Pearson, T., Zwanziger, J., Mukamel, D.
(2004). Explaining disparities in access to high-quality cardiac surgeons. Ann. Thorac. Surg.
78: 18-24
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Morales, L. S., Rogowski, J., Freedman, V. A., Wickstrom, S. L., Adams, J. L., Escarce, J. J.
(2004). Use of Preventive Services by Men Enrolled in Medicare+Choice Plans. AJPH
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Berger, J. T., Coulehan, J., Belling, C.
(2004). Humor in the Physician-Patient Encounter. Arch Intern Med
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Freudenberg, N.
(2004). Community Health Services for Returning Jail and Prison Inmates. J Correct Health Care
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Virnig, B., Huang, Z., Lurie, N., Musgrave, D., McBean, A. M., Dowd, B.
(2004). Does Medicare Managed Care Provide Equal Treatment for Mental Illness Across Races?. Arch Gen Psychiatry
61: 201-205
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Egede, L. E., Zheng, D.
(2003). Racial/Ethnic Differences in Influenza Vaccination Coverage in High-Risk Adults. AJPH
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Rucker-Whitaker, C., Feinglass, J., Pearce, W. H.
(2003). Explaining Racial Variation in Lower Extremity Amputation: A 5-Year Retrospective Claims Data and Medical Record Review at an Urban Teaching Hospital. Arch Surg
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Rosen, A. B., Tsai, J. S., Downs, S. M.
(2003). Variations in Risk Attitude across Race, Gender, and Education. Med Decis Making
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Dunlop, D. D., Song, J., Lyons, J. S., Manheim, L. M., Chang, R. W.
(2003). Racial/Ethnic Differences in Rates of Depression Among Preretirement Adults. AJPH
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Serna, D. S., Lee, S. J., Zhang, M.-j., Baker, K. S., Eapen, M., Horowitz, M. M., Klein, J. P., Rizzo, J. D., Loberiza, F. R. Jr
(2003). Trends in Survival Rates After Allogeneic Hematopoietic Stem-Cell Transplantation for Acute and Chronic Leukemia by Ethnicity in the United States and Canada. JCO
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Ibrahim, S. A., Thomas, S. B., Fine, M. J.
(2003). Achieving Health Equity: An Incremental Journey. AJPH
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Saha, S., Arbelaez, J. J., Cooper, L. A.
(2003). Patient-Physician Relationships and Racial Disparities in the Quality of Health Care. AJPH
93: 1713-1719
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Studdert, D. M., Burns, J. P., Mello, M. M., Puopolo, A. L., Truog, R. D., Brennan, T. A.
(2003). Nature of Conflict in the Care of Pediatric Intensive Care Patients With Prolonged Stay. Pediatrics
112: 553-558
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Stein, P. D., Hull, R. D., Patel, K. C., Olson, R. E., Ghali, W. A., Alshab, A. K., Meyers, F. A.
(2003). Venous Thromboembolic Disease: Comparison of the Diagnostic Process in Blacks and Whites. Arch Intern Med
163: 1843-1848
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Gorelick, P. B., Richardson, D., Kelly, M., Ruland, S., Hung, E., Harris, Y., Kittner, S., Leurgans, S.
(2003). Aspirin and Ticlopidine for Prevention of Recurrent Stroke in Black Patients: A Randomized Trial. JAMA
289: 2947-2957
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Becker, G., Newsom, E.
(2003). Socioeconomic Status and Dissatisfaction With Health Care Among Chronically Ill African Americans. AJPH
93: 742-748
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Gornick, M. E.
(2003). A Decade of Research on Disparities in Medicare Utilization: Lessons for the Health and Health Care of Vulnerable Men. AJPH
93: 753-759
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Massing, M. W., Henley, N. S., Carter-Edwards, L., Schenck, A. P., Simpson, R. J. Jr.
(2003). Lipid Testing Among Patients With Diabetes Who Receive Diabetes Care From Primary Care Physicians. Diabetes Care
26: 1369-1373
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Goldstein, L. B., Matchar, D. B., Hoff-Lindquist, J., Samsa, G. P., Horner, R. D., Kenton, E. J. III
(2003). Veterans Administration Acute Stroke (VASt) Study: Lack of Race/Ethnic-Based Differences in Utilization of Stroke-Related Procedures or Services * Diagnostic Disparities: Still Exist?. Stroke
34: 999-1004
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Cykert, S., Phifer, N.
(2003). Surgical Decisions for Early Stage, Non-Small Cell Lung Cancer: Which Racially Sensitive Perceptions of Cancer Are Likely to Explain Racial Variation in Surgery?. Med Decis Making
23: 167-176
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Daumit, G. L., Crum, R. M., Guallar, E., Powe, N. R., Primm, A. B., Steinwachs, D. M., Ford, D. E.
(2003). Outpatient Prescriptions for Atypical Antipsychotics for African Americans, Hispanics, and Whites in the United States. Arch Gen Psychiatry
60: 121-128
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Virnig, B. A., Lurie, N., Huang, Z., Musgrave, D., McBean, A. M., Dowd, B.
(2002). Racial Variation In Quality Of Care Among Medicare+Choice Enrollees. Health Aff (Millwood)
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Martin, A., Whittle, L., Levit, K., Won, G., Hinman, L.
(2002). Health Care Spending During 1991-1998: A Fifty-State Review. Health Aff (Millwood)
21: 112-126
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Karter, A. J., Ferrara, A., Liu, J. Y., Moffet, H. H., Ackerson, L. M., Selby, J. V.
(2002). Ethnic Disparities in Diabetic Complications in an Insured Population. JAMA
287: 2519-2527
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Klassen, A. C., Hall, A. G., Saksvig, B., Curbow, B., Klassen, D. K.
(2002). Relationship Between Patients' Perceptions of Disadvantage and Discrimination and Listing for Kidney Transplantation. AJPH
92: 811-817
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Bierman, A. S., Lurie, N., Collins, K. S., Eisenberg, J. M.
(2002). Addressing Racial And Ethnic Barriers To Effective Health Care: The Need For Better Data. Health Aff (Millwood)
21: 91-102
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Earp, J. A., Eng, E., O'Malley, M. S., Altpeter, M., Rauscher, G., Mayne, L., Mathews, H. F., Lynch, K. S., Qaqish, B.
(2002). Increasing Use of Mammography Among Older, Rural African American Women: Results From a Community Trial. AJPH
92: 646-654
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Schneider, E. C., Zaslavsky, A. M., Epstein, A. M.
(2002). Racial Disparities in the Quality of Care for Enrollees in Medicare Managed Care. JAMA
287: 1288-1294
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White, A. A. III
(2002). Alfred R. Shands, Jr., Lecture: Our Humanitarian Orthopaedic Opportunity. JBJS
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Leeman, J., Harrell, J. S., Funk, S. G.
(2002). Building a Research Program Focused on Vulnerable People. West J Nurs Res
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Legler, J., Meissner, H. I., Coyne, C., Breen, N., Chollette, V., Rimer, B. K.
(2002). The Effectiveness of Interventions To Promote Mammography among Women with Historically Lower Rates of Screening. Cancer Epidemiol. Biomarkers Prev.
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Warren, J. L., Brown, M. L., Fay, M. P., Schussler, N., Potosky, A. L., Riley, G. F.
(2002). Costs of Treatment for Elderly Women With Early-Stage Breast Cancer in Fee-for-Service Settings. JCO
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Schneider, E. C., Cleary, P. D., Zaslavsky, A. M., Epstein, A. M.
(2001). Racial Disparity in Influenza Vaccination: Does Managed Care Narrow the Gap Between African Americans and Whites?. JAMA
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Kressin, N. R., Petersen, L. A.
(2001). Racial Differences in the Use of Invasive Cardiovascular Procedures: Review of the Literature and Prescription for Future Research. ANN INTERN MED
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Okelo, S., Taylor, A. L., Wright, J. T. Jr, Gordon, N., Mohan, G., Lesnefsky, E.
(2001). Race and the decision to refer for coronary revascularization: The effect of physician awareness of patient ethnicity. J Am Coll Cardiol
38: 698-704
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Sambamoorthi, U., Moynihan, P. J., McSpiritt, E., Crystal, S.
(2001). Use of Protease Inhibitors and Non-Nucleoside Reverse Transcriptase Inhibitors Among Medicaid Beneficiaries With AIDS. AJPH
91: 1474-1481
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Goins, R. T., Hays, J. C., Landerman, L. R., Hobbs, G.
(2001). Access to Health Care and Self-Rated Health Among Community-Dwelling Older Adults. Journal of Applied Gerontology
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Richardus, J. H., Kunst, A. E.
(2001). Black-White Differences in Infectious Disease Mortality in the United States. AJPH
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Auchincloss, A. H., van Nostrand, J. F., Ronsaville, D.
(2001). Access to Health Care for Older Persons in the United States: Personal, Structural, and Neighborhood Characteristics. J Aging Health
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Jones, J. W.
(2001). The question of racial bias in thoracic surgery: appearances and realities. Ann. Thorac. Surg.
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Geiger, H. J.
(2001). Racial stereotyping and medicine: the need for cultural competence. CMAJ
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Edelman, D.
(2001). Rate and Predictors of Glycemic Testing of Nondiabetic Patients in a Managed Care Population. Diabetes Care
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Johnston, S. C., Fung, L. H., Gillum, L. A., Smith, W. S., Brass, L. M., Lichtman, J. H., Brown, A. N., Wang, D. Z.
(2001). Utilization of Intravenous Tissue-Type Plasminogen Activator for Ischemic Stroke at Academic Medical Centers : The Influence of Ethnicity Editorial Comment : It Is Time to Implement Stroke Practice Improvement Programs and Prevent the Racial Disparity in Stroke Care. Stroke
32: 1061-1068
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Sheikh, K., Bullock, C.
(2001). Urban-Rural Differences in the Quality of Care for Medicare Patients With Acute Myocardial Infarction. Arch Intern Med
161: 737-743
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Miller, N. A., Ramsland, S., Goldstein, E., Harrington, C.
(2001). Use of Medicaid 1915(c) Home- and Community-Based Care Waivers to Reconfigure State Long-Term Care Systems. Med Care Res Rev
58: 100-119
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Tierney, E., Geiss, L., Engelgau, M., Thompson, T., Schaubert, D, Shireley, L., Vukelic, P., McDonough, S.
(2001). Population-based estimates of mortality associated with diabetes: use of a death certificate check box in North Dakota. AJPH
91: 84-92
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Gaskin, D. J., Hoffman, C.
(2000). Racial and Ethnic Differences in Preventable Hospitalizations across 10 States. Med Care Res Rev
57: 85-107
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Mayberry, R. M., Mili, F., Ofili, E.
(2000). Racial and Ethnic Differences in Access to Medical Care. Med Care Res Rev
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Brach, C., Fraserirector, I.
(2000). Can Cultural Competency Reduce Racial and Ethnic Health Disparities? a Review and Conceptual Model. Med Care Res Rev
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Epstein, A. M., Ayanian, J. Z., Keogh, J. H., Noonan, S. J., Armistead, N., Cleary, P. D., Weissman, J. S., David-Kasdan, J. A., Carlson, D., Fuller, J., Marsh, D., Conti, R. M.
(2000). Racial Disparities in Access to Renal Transplantation -- Clinically Appropriate or Due to Underuse or Overuse?. NEJM
343: 1537-1544
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Young, C. J., Gaston, R. S.
(2000). Renal Transplantation in Black Americans. NEJM
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Crawley, L., Payne, R., Bolden, J., Payne, T., Washington, P., Williams, S., for the Initiative to Improve Palliative and End-o,
(2000). Palliative and End-of-Life Care in the African American Community. JAMA
284: 2518-2521
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Doescher, M. P., Saver, B. G., Franks, P., Fiscella, K.
(2000). Racial and Ethnic Disparities in Perceptions of Physician Style and Trust. Arch Fam Med
9: 1156-1163
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Jones Jr., M. D., Boat, T., Adler, R., Gephart, H. R., Osborn, L. M., Mulvey, H. J., Alden, E. R., Simon, J. L., Chesney, R. W.
(2000). Final Report of the FOPE II Financing of Pediatric Education Workgroup. Pediatrics
106: 1256e-1256
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