Unequal Utilization of New Technologies by Race

The Use of New Prostate Surgeries (TUNA and TUMT) among Medicare Elderly Beneficiaries

Xinhua Yu, PhD, MBBSA. Marshall McBean, MD, MSc

Debra S. Caldwell, MSResearch Data Assistance Center

University of Minnesota

Janet A. Anderson Centers for Medicare and Medicaid Services

AcademyHealth Annual Research Meeting June 7, 2004

Benign Prostate Hypertrophy (BPH)

Enlargement of prostate gland Enlargement causes obstruction of

outflow of urine and results in symptoms that significantly affect the quality of life

BPH affects three out of four men aged 70 or above

The prevalence of BPH for Blacks and Whites is not significantly different (Platz EA, Urology 59, 2002)

Treatment Surgical:

transurethral resection of prostate (TURP) transurethral microwave thermotherapy

(TUMT) transurethral needle ablation of prostate

(TUNA) Others (laser, electropulvarization, etc.)

Medical: Watchful waiting Drugs: alpha-blockers, finasteride

Rationale for Study Black elderly Medicare beneficiaries have lower

rates of many surgical procedures than Whites TURP is performed 10% more frequently among

elderly Whites than among Blacks (Wasson JH , J Urol. 2000 164(4))

New BPH surgeries do not require hospitalization and are not known to have any different side effects or complications than TURP

Little is known about the access (use) of new procedures in general, by race, and these new BPH procedures, in particular

Objective and Hypothesis

Examine racial difference of new BPH surgical procedures (TUMT and TUNA) among elderly Medicare beneficiaries H0 - Blacks and Whites will receive

new BPH surgical procedures at equal rates

Data Source/Case Identification 100% Medicare claims and Denominator files

from CMS Identified any BPH procedures in Carrier,

Inpatient, or Outpatient claim file from 1999-2001

BPH procedure: CPT code: TURP (52601, 52612, 52614); TUMT

(53850); TUNA (53852) ICD 9-CM procedure code: TURP (60.29); TUMT

(60.96); TUNA (60.97) For procedures done in hospital or hospital

out-patient, we matched physician and institution claims to avoid duplication

Inclusion Criteria Black and white men only Age ≥ 65 Enrolled in both Medicare Part A

and Part B during the study years Not in managed care during the

study years No End Stage Renal Disease No history of prostate cancer

Study Cohort

Total sample size: 140,207 patients

    % Total US Beneficiaries

  Counties Whites Blacks

Overall

TUMT 631 57% 69%

TUNA 409 46% 57%

TUMT/TUNA 783 64% 74%

Restricted

TUMT 558 55% 69%

TUNA 378 45% 57%

TUMT/TUNA 690 63% 74%

Statistical Analysis Separate analysis for

Total U.S. those counties where new procedures were

performed and had 10 or more black elderly male beneficiaries

Race-specific procedure rates per 10,000 person years

Direct standardization for age adjustment Geographic heterogeneity was adjusted using

Generalized Estimate Equation model (GEE), Poisson regression were used for adjusted rate ratios

Table 1: Age Adjusted BPH Procedure Rates among all U.S. Medicare Beneficiaries, 1999-2001

Rate: per 10,000 person years

  Whites Blacks

 Rate ratioProcedures Rate Procedures Rate

TURP 111,655 43.2 7,624 39.3 1.10

TUMT 15,479 6.0 547 2.8 2.14

TUNA 4,713 1.8 189 1.0 1.88

TUMT/TUNA 20,192 7.8 736 3.8 2.05

Table 2: Age Adjusted Procedure Rates among Medicare Beneficiaries in Procedure Counties, 1999-2001

Rate: per 10,000 person years

  Whites   Blacks  

Rate ratio  Procedures Rate Procedures Rate

TURP 71337 42.9 5708 40.0 1.07

TUMT 10996 7.7 468 3.5 2.23

TUNA 3414 2.9 167 1.5 1.93

TUMT/TUNA 14860 9.2 643 4.4 2.07

Note: Colored areas were restricted counties

* Purple color: Procedure performed only in Whites

Table 3: White/Black Rate Ratio Adjusted for Geographic Variation among Medicare beneficiaries, 1999-2001

Data were restricted counties

CI: confidence interval

ProceduresUnadjusted Rate Ratio

Adjusted Rate Ratio(95% CI) p-value

TURP 1.07 1.10 (1.01,1.20) 0.0259

TUMT 2.23 1.67 (1.48,1.89) <.0001

TUNA 1.93 1.51 (1.18,1.94) 0.0012

TUMT/TUNA 2.07 1.68 (1.48,1.91) <.0001

Conclusion White:Black rate ratio for TURP are

consistent with past reports and are an appropriate surrogate for the need for new surgery (RR=1.1)

Nationally, elderly Black Medicare beneficiaries were significantly less likely to receive new BPH surgical procedures than Whites (RR=2.1)

After adjusting for geographic variation, differences between the races persist (RR=1.7)

Discussion Racial difference not due to

availability of procedure Severity of BPH Patient preference Cost to patient – future study

Acknowledgement

Research Data Assistance Center(ResDAC), University of Minnesota

Coverage and Analysis Group, Centers for Medicare and Medicaid Services (CMS)

Supported by CMS contract CMS 500-01-0043