1. In this cross-sectional study of Medicare Advantage enrollees, Puerto Rican Hispanics received lower quality of care than Hispanics and non-Hispanics in the United States based on 17 health-related performance measures related to diabetes, cardiovascular disease, cancer screening, and evidence-based medication use.
2. Major efforts are needed to ensure similar care, particularly in the domain of appropriate medication use, on the island of Puerto Rico as available in the continental United States.
Evidence Rating Level: 3 (Average)
Study Rundown: Socioeconomic, ethnic and geographic variations in health-related and quality of care outcomes in the US are well documented. However, few Medicare studies have included Puerto Rico. The inclusion of Puerto Rico is important given that a high proportion of Puerto Ricans are enrolled in the Medicare Advantage (MA) program, the territory’s lower economic and health conditions, and the increased constraint on funding for Puerto Rico’s Medicaid and low-income assistance programs. This cross-sectional study aimed to determine the quality of care provided to white and Hispanic MA enrollees in the USA and Puerto Rico.
Puerto Rican Hispanic MA enrollees received lower quality of care compared with Hispanics and non-Hispanics in the continental US based on 17 health-related performance measures. Hispanic MA enrollees living in the continental US also received lower quality of care than white Americans in 16 of 17 health-related performance measures, however the absolute differences were modest. While the study did use important health-quality measures for their comparisons, there were not enough data on socioeconomic differences in the groups being studied, which may have significant contributions on health outcomes given the high poverty rates in Puerto Rico.
Relevant Reading: Quality of care in the US Territories
In-Depth [cross-sectional study]: This cross-sectional study used the 2011 Healthcare Effectiveness Data and Information Set (HEDIS) for Medicare Advantage plans from the Centers for Medicare & Medicaid Services. This dataset included white, Hispanic MA enrollees living in the United States and Hispanic MA enrollees living in Puerto Rico. The outcome variables were 17 HEDIS quality measures related to diabetes, cardiovascular disease, cancer screening, and appropriate medication usage. Demographic and socioeconomic information was also gathered from HEDIS. Statistical analysis included X2 and unpaired 2-tailed t tests.
Of the 7.35 million MA enrollees, 14.4% were Hispanic Americans living in the continental United States or Puerto Rico. Median zip code-level rates of poverty were 10.7% among white MA enrollees, 16.3% among Hispanic MA enrollees in the United States and 47.9% among Hispanic MA enrollees in Puerto Rico (P<0.001). Fifteen of 17 performance measures were significantly lower (P<0.01) in Puerto Rican Hispanics as compared with Hispanics living in the United States. These measures included: annual HbA1c testing, prevalence of HbA1c >9%, retinal eye examinations, LDL-C levels <100 mg/dL, nephropathy testing, BP control <140/90, LDL-C testing after coronary event, LDL-C<100 mg/dL after coronary event, BP control <140/90 in hypertension, beta-blocker treatment after MI, receipt of ≥ 1 high risk medication, use of disease-modifying antirheumatic drug therapy, use of systemic corticosteroids in COPD exacerbation, use of bronchodilator therapy in COPD exacerbation, and breast cancer screening. The adjusted absolute differences in performance rates ranged from 12.5% to -23.8%. Hispanic MA enrollees residing in the United States also had poorer quality of care outcomes in 16 of 17 performance health measures as compared to Caucasians, however the rate differences were much smaller (adjusted absolute difference range: 6.8% to -5.1%).
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