将医疗服务中的种族差异归因于医疗计划的绩效或选择。

IF 22.5 1区 医学 Q1 MEDICINE, GENERAL & INTERNAL
Jacob Wallace, Chima D Ndumele, Anthony Lollo, Danil Agafiev Macambira, Matthew Lavallee, Beniamino Green, Kate A Duchowny, J Michael McWilliams
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引用次数: 0

摘要

重要性:人们越来越关注公开报告机构在健康公平指标方面的表现并将经济激励与之挂钩,但机构间的差异可能反映了表现差异或选择偏差:评估各医疗计划在性别和年龄调整后的种族差异方面的差异是否与绩效或选择偏差有关:这项横断面研究利用了一个自然实验,即美国南部一个州在 2012 年转向管理式医疗后,将其大部分医疗补助人群随机分配到 5 个计划中的 1 个。研究人员获得了 2011 年至 2015 年自我认同的黑人和白人参保者的参保者级别的行政报销和注册数据。分析仅限于黑人和白人医疗补助参保者,因为他们在人口中所占的比例最大,与其他群体相比,他们的比较具有更强的统计能力。数据分析时间为 2021 年 6 月至 2024 年 9 月:主要结果和测量指标:主要结果和测量指标:初级保健年就诊次数、低急性急诊就诊次数、处方药使用量和总支出。对于观察人群和随机人群,每种结果的模型都与计划指标、种族指标、计划指标与种族之间的交互作用以及年龄和性别相关。模型估计了每个计划中种族差异的程度,并测试了不同计划中种族差异的程度是否不同:在 118 101 名参保者(平均 [SD] 年龄为 9.3 [7.5] 岁;53.0% 为女性;61.4% 为非西班牙裔黑人;38.6% 为非西班牙裔白人)中,70.2% 被纳入随机人群,29.8% 被纳入观察人群。在随机人群中,黑人和白人参保者在初级保健就诊、低急性急诊就诊、处方药使用和总支出方面的计划内差异较大,但差异不大,而且不同计划之间的差异在统计学上也不显著,这表明计划对这些指标的种族差异影响很小。相反,在观察人群中,不同计划之间的种族差异很大(标准差是随机人群的 2-3 倍);经多重测试调整后,除急诊就诊外,这种差异在统计学上具有显著性。抽样误差只能部分解释观察人群种族差异在计划间的较大差异。按种族进行分层并未使计划效应的观察估计值更接近随机估计值:这项横断面研究表明,选择偏差可能会错误地描述医疗计划在衡量医疗差距方面的相对表现。解决医疗补助中的差异问题至关重要,但根据差异测量结果调整计划付款可能会产生意想不到的后果。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Attributing Racial Differences in Care to Health Plan Performance or Selection.

Importance: There is increased interest in public reporting of, and linking financial incentives to, the performance of organizations on health equity metrics, but variation across organizations could reflect differences in performance or selection bias.

Objective: To assess whether differences across health plans in sex- and age-adjusted racial disparities are associated with performance or selection bias.

Design, setting, and participants: This cross-sectional study leveraged a natural experiment, wherein a southern US state randomly assigned much of its Medicaid population to 1 of 5 plans after shifting to managed care in 2012. Enrollee-level administrative claims and enrollment data from 2011 to 2015 were obtained for self-identified Black and White enrollees. The analyses were limited to Black and White Medicaid enrollees because they accounted for the largest percentages of the population and could be compared with greater statistical power than other groups. Data were analyzed from June 2021 to September 2024.

Exposures: Plan enrollment via self-selection (observational population) vs random assignment (randomized population).

Main outcomes and measures: Annual counts of primary care visits, low-acuity emergency department visits, prescription drug fills, and total spending. For observational and randomized populations, models of each outcome were fit as a function of plan indicators, indicators for race, interactions between plan indicators and race, and age and sex. Models estimated the magnitude of racial differences within each plan and tested whether this magnitude varied across plans.

Results: Of 118 101 enrollees (mean [SD] age, 9.3 [7.5] years; 53.0% female; 61.4% non-Hispanic Black; and 38.6% non-Hispanic White), 70.2% were included in the randomized population, and 29.8% were included in the observational population. Within-plan differences in primary care visits, low-acuity emergency department visits, prescription drug use, and total spending between Black and White enrollees were large but did not vary substantially and were not statistically significantly different across plans in the randomized population, suggesting minimal effects of plans on racial differences in these measures. In contrast, in the observational population, racial differences varied substantially across plans (standard deviations 2-3 times greater than in the randomized population); this variation was statistically significant after adjustment for multiple testing, except for emergency department visits. Greater between-plan variation in racial differences in the observational population was only partially explained by sampling error. Stratifying by race did not bring observational estimates of plan effects meaningfully closer to randomized estimates.

Conclusions and relevance: This cross-sectional study showed that selection bias may mischaracterize plans' relative performance on measures of health care disparities. It is critical to address disparities in Medicaid, but adjusting plan payments based on disparity measures may have unintended consequences.

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来源期刊
JAMA Internal Medicine
JAMA Internal Medicine MEDICINE, GENERAL & INTERNAL-
CiteScore
43.50
自引率
1.30%
发文量
371
期刊介绍: JAMA Internal Medicine is an international, peer-reviewed journal committed to advancing the field of internal medicine worldwide. With a focus on four core priorities—clinical relevance, clinical practice change, credibility, and effective communication—the journal aims to provide indispensable and trustworthy peer-reviewed evidence. Catering to academics, clinicians, educators, researchers, and trainees across the entire spectrum of internal medicine, including general internal medicine and subspecialties, JAMA Internal Medicine publishes innovative and clinically relevant research. The journal strives to deliver stimulating articles that educate and inform readers with the latest research findings, driving positive change in healthcare systems and patient care delivery. As a member of the JAMA Network, a consortium of peer-reviewed medical publications, JAMA Internal Medicine plays a pivotal role in shaping the discourse and advancing patient care in internal medicine.
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