Reducing disparities by providing access
Journal of the American Geriatrics Society
February, 2003
Differences in Mortality of Black and White Patients Enrolled in the Program of All-Inclusive Care for the Elderly
By Erwin J. Tan, Li-Yung Lui, Catherine Eng, Ashish K. Jha & Kenneth E. Covinsky
Abstract
OBJECTIVES: To examine the relationship between race and mortality in frail community-dwelling older people with access to a program providing comprehensive access and coordination of services.
DESIGN: A longitudinal cohort study.
SETTING: Twelve nationwide demonstration sites of the Program of All-Inclusive Care for the Elderly (PACE) from 1990 to 1996. PACE provides comprehensive medical and long-term care services for nursing home-eligible older people who live in the community.
PARTICIPANTS: Two thousand two white patients and 859 black patients.
MEASUREMENTS: Patients were followed after enrollment until death or the end of the follow-up period. Time from enrollment to death was measured with adjustment of the Cox proportional hazards model for comorbid conditions, functional status, site, and other demographic characteristics.
RESULTS: Black patients were younger than white patients (mean age 77 vs 80, P < .001) but had worse functional status (mean activity of daily living (ADL) score 6.5 vs 7.2, P < .001) on enrollment. Survival for black and white patients was 88% and 86% at 1 year, 67% and 61% at 3 years, and 51% and 42% at 5 years, respectively (unadjusted hazard ratio (HR) for black patients = 0.77; 95% confidence interval (CI) = 0.67-0.89). After adjustment for baseline comorbid conditions, functional status, site, and demographic characteristics, black patients still had a lower mortality rate (HR = 0.77; 95% CI = .65-0.93). The survival advantage for black patients did not emerge until about 1 year after PACE enrollment (HR for first year after enrollment = 0.97; 95% CI = 0.72-1.31; HR after first year = 0.67; 95% CI = 0.54-0.85, P-value for time interaction < .001). During the first year of enrollment, black patients were more likely to improve and less likely to decline in ADL function than white patients (P < .001).
CONCLUSION: In PACE, a system providing access to and coordination of comprehensive medical and long-term care services for frail older people, black patients have a lower mortality rate than white patients. This survival advantage, which emerges approximately 1 year after PACE enrollment, may be related to the comprehensive access and coordination of services provided by the PACE program. J Am Geriatr Soc 51:246-251, 2003.
http://www.blackwellpublishing.com/abstract.asp?ref=0002-8614&vid=51&iid=2&aid=16&s=
Comment: Impaired access is clearly a major contributor to heath care disparities. The significance of this study is that it demonstrates that providing access to comprehensive services was followed by an elimination of these disparities.
The first step in assuring access is to eliminate financial barriers to care by establishing a universal, comprehensive health insurance program. The PACE program is unique, and undoubtedly many other measures will be required to reduce disparities in other situations. But eliminating disparities is virtually impossible without an equitable system of funding health care.