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
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