William H. Hung, MD, MPH
Addressing health disparities related to race, ethnicity, and socioeconomic factors such as poverty is an important public health goal. Equal access to quality care is especially important for older adults, as they may consume more healthcare services and have other factors that contribute to health and healthcare disparities, such as functional limitations and multiple chronic conditions. Three recent studies explored disparities experienced by older adults across settings, providing important lessons for policymakers and health system leaders as they work to develop policies and strategies to ensure quality care regardless of race, ethnicity, and socioeconomic status.
Neighborhood Disadvantage
Increasing evidence suggests that people living in disadvantaged neighborhoods have worse health outcomes. A prospective longitudinal cohort study examined the association between living in a disadvantaged neighborhood and functional outcomes using data from a cohort of 754 community-living adults aged 70 years or older who did not have disability at baseline. The cohort was established in 1998 and 1999 and was followed until June 2020. To identify those who were disabled, participants were asked monthly whether they needed help with activities of daily living, including bathing, dressing, walking, or transferring. Neighborhood disadvantage was assessed with the Area Deprivation Index, which includes census-based indicators of education, employment, housing quality, and poverty, providing scores used to dichotomize neighborhoods as disadvantaged and non-disadvantaged
The mean age of the cohort was 78.4 years and 64.6% were female. The disadvantaged group’s estimated active life expectancy at age 70 was 12.3 years vs 14.2 years in the non-disadvantaged group. Participants from disadvantaged neighborhoods were projected to have a higher percentage of their expected remaining life disabled compared with those living in non-disadvantaged neighborhoods.
In this study, older adults living in disadvantaged neighborhoods experienced diminished functional well-being as they aged. Neighborhood disadvantage is a potentially modifiable factor. However, significant additional resources and funding for social and public health interventions are needed to address these health disparities in disadvantaged neighborhoods.
Racial Disparities in Health Status and Healthcare
A recent study used data from the National Health Interview Survey to examine racial and ethnic differences in self-reported health status, access, and affordability during the years 1998 to 2018. The study included 596,355 adults who were 18 years of age or older during the study period; mean age was 46.2 years, and just over half (51.8%) were women. The study population was 4.7% Asian, 11.8% Black, 13.8% Latino/Hispanic, and 69.7% White. Approximately 17% of the study population was 65 years of age or older.
Poor or fair health status was reported by approximately 10% of Asian, 17.7% of Black, 14.3% of Latino/Hispanic, and 9.4% of White individuals, and there was no significant change in the health status gap between White and Black or Latino individuals over the 20-year study period. Although the uninsured rate decreased significantly for all racial and ethnic groups, these rates remained 3% higher among Black (compared with White) individuals and 12.2% higher among Latino/Hispanic (compared with non-Latino/Hispanic) individuals.
Foregone or delayed medical care due to cost was reported by 6.7% of Asian, 13.6% of Black, 12.1% of Latino/Hispanic, and 10.7% of White individuals in 1999. Rates of foregone or delayed medical care due to cost increased among White, Black, and Latino/Hispanic individuals, and the differences across race and ethnicity did not change significantly throughout the study period.
Differences in self-reported health status, access, and affordability by race and ethnicity persisted across the 20-year study period ending in 2018. Despite a decrease in the prevalence of uninsured persons, which was largely associated with the passage of the Affordable Care Act, the prevalence of foregone or delayed medical care due to cost increased, suggesting that healthcare is not more affordable now than it was 20 years ago.
Racial Disparities and Dementia
Older adults living with Alzheimer’s disease and related dementia often experience progressive worsening of cognitive symptoms, and those with severe dementia often have eating problems that lead to pneumonia, aspiration, and ultimately death. At the end of life when dementia is severe, advance care planning and communication with healthcare proxies and surrogates often results in more coordinated care and avoids acute hospitalizations.
This study evaluated outcomes for decedents with dementia who spent their end of life in a nursing home in 2014 to 2017. Data were obtained from national Medicare data and the Minimum Data Set, which are collected at all nursing homes across the country. A total of 598,502 decedents were White and 66,531 decedents were Black. The outcome variable was a hospitalization event within 30 days of death. Approximately 25.9% of White decedents and 40.7% of Black decedents were hospitalized. Black residents were 7.9% more likely to be hospitalized in the last 30 days of life compared with White residents. Compared with nursing homes having no Black residents, those with a low proportion of Black residents had a 5.17% higher risk for hospitalizations, and those with a higher percentage of Black residents had a 13.3% higher risk for hospitalization.
Black nursing home residents were more likely than White nursing home residents to be transferred to the hospital at the end of life, which is a marker of poorer quality of care. This study highlights disparities in care quality across nursing homes with different racial mixes. Nursing homes in this study with a larger proportion of minority residents had fewer resources and delivered poorer-quality care, making the case that systemic disparities can contribute to differences in quality of care for this vulnerable group of older adults.