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Original research
Race, sex and age disparities in echocardiography among Medicare beneficiaries in an integrated healthcare system
  1. Patrick M Hyland1,2,
  2. Jiaman Xu2,3,
  3. Changyu Shen2,3,
  4. Lawrence J Markson2,4,
  5. Warren J Manning2,5,
  6. Jordan B. Strom1,2,3
  1. 1Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  2. 2Harvard Medical School, Boston, Massachusetts, USA
  3. 3Beth Israel Deaconess Medical Center, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Boston, Massachusetts, USA
  4. 4Information Systems, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  5. 5Departments of Medicine (Cardiovascular Division) and Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  1. Correspondence to Dr Jordan B. Strom, Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center, Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Boston, MA 02215, USA; jstrom{at}bidmc.harvard.edu

Abstract

Objective To identify potential race, sex and age disparities in performance of transthoracic echocardiography (TTE) over several decades.

Methods TTE reports from five academic and community sites within a single integrated healthcare system were linked to 100% Medicare fee-for-service claims from 1 January 2005 to 31 December 2017. Multivariable Poisson regression was used to estimate adjusted rates of TTE utilisation after the index TTE according to baseline age, sex, race and comorbidities among individuals with ≥2 TTEs. Non-white race was defined as black, Asian, North American Native, Hispanic or other categories using Medicare-assigned race categories.

Results A total of 15 870 individuals (50.1% female, mean 72.2±12.7 years) underwent a total of 63 535 TTEs (range 2–55/person) over a median (IQR) follow-up time of 4.9 (2.4–8.5) years. After the index TTE, the median TTE use was 0.72 TTEs/person/year (IQR 0.43–1.33; range 0.12–26.76). TTE use was lower in older individuals (relative risk (RR) for 10-year increase in age, 0.91, 95% CI 0.89 to 0.92, p<0.001), women (RR 0.97, 95% CI 0.95 to 0.99, p<0.001) and non-white individuals (RR 0.95, 95% CI 0.93 to 0.97, p<0.001). Black women in particular had the lowest relative use of TTE (RR 0.92, 95% CI 0.88 to 0.95, p<0.001). The only clinical conditions associated with increased TTE use after multivariable adjustment were heart failure (RR 1.04, 95% CI 1.00 to 1.08, p=0.04) and chronic obstructive pulmonary disease (RR 1.05, 95% CI 1.00 to 1.10, p=0.04).

Conclusions Among Medicare beneficiaries with multiple TTEs in a single large healthcare system, the median TTE use after the index TTE was 0.72 TTEs/person/year, although this varied widely. Adjusted for comorbidities, female sex, non-white race and advancing age were associated with decreased TTE utilisation.

  • echocardiography
  • quality of health care
  • delivery of health care

Data availability statement

No data are available. The data supporting this study are not publicly available due to prior data use agreements with Medicare.

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Data availability statement

No data are available. The data supporting this study are not publicly available due to prior data use agreements with Medicare.

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Footnotes

  • Twitter @DocStrom

  • Contributors PMH and JBS designed and conceptualised the study. JBS obtained funding. LJM and WM obtained and managed the data. JX, CS and JBS performed the statistical analysis. PMH and JBS wrote the manuscript. PMH, WM and JBS provided critical revisions to the manuscript. All authors claim responsibility for the manuscript content.

  • Funding JBS reports funding from the National Heart, Lung, and Blood Institute (1K23HL144907).

  • Competing interests JBS reports additional grant support from Edwards Lifesciences, Ultromics and HeartSciences, consulting for Bracco Diagnostics, and speaker fees from Northwest Imaging Forums, unrelated to the submitted work. CS is an employee of Biogen.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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