Increasing access to care could reverse disparities, study suggests

By Camille Mojica Rey

Providing frail elderly African Americans with comprehensive health care may improve their health status and decrease mortality rates to levels in line with those of their white counterparts, according to a study by researchers at the San Francisco VA Medical Center (SFVAMC).

“It may never be too late to improve health outcomes by increasing people’s access to care,” said Erwin Tan, MD, UCSF assistant clinical professor of medicine. Tan conducted this study while a clinical researcher at the SFVAMC. He currently practices at SF General Hospital Medical Center.

Numerous studies have described the health disparities between African Americans and whites, showing that African Americans receive less health care and are more likely to die from the same illness than their white counterparts. This study is unique in that it describes a setting in which these disparities are reversed, allowing African Americans to live longer, healthier lives.

The current study appears in the February issue of the Journal of the American Geriatric Society.
Tan and his colleagues found that providing integrated medical and health care services actually allowed African American patients to fare better than whites over time. The researchers compared health status and survival rates of elderly African American and white participants enrolled at 12 nationwide sites of the Program of All-Inclusive Care for the Elderly (PACE) between 1990 and 1996. A total of 859 African American patients and 2002 white patients were included in the study.

Upon enrolling in PACE, African American patients were younger and more disabled by their illnesses than white patients, scoring significantly lower on measures of mental health, ability to perform routine tasks and degree of dementia. African Americans were, however, more likely to improve in health status than whites after their first year. After a year of enrollment in PACE, African American patients had a survival rate of 88 percent, slightly higher than the 86 percent for white patients. After five years, survival rates were 51 percent and 42 percent, respectively.

“These are all patients who are sick enough and disabled enough to live in nursing homes. PACE gives these people the services they need to continue to live at home.

In our study, African American patients enrolled in PACE programs did better than we expected,” Tan said.

PACE is a model of care created in the 1971 in San Francisco’s Chinatown by On Lok Senior Health. It was approved for Medicare reimbursement in 1997 and, since then, more than 70 organizations in 30 states have established programs based on the PACE model.

Tan attributes the success of PACE to its comprehensive, team approach. Each PACE team consists of a range of providers; including primary care physicians, dentists, dieticians, podiatrists, nurses and physical therapists. Even the drivers who provide patients with transportation to their medical appointments are included in the team’s meetings held two to four times a year to discuss a patient’s progress.

Tan said he hopes the results of this study encourage more communities to adopt the PACE model. “PACE is a national program that has already been successfully exported to other cities,” Tan said. 

Tan also said more research is needed to identify other ways of reversing racial disparities in health outcomes and prevent these disparities from developing in the first place. But, the current study offers hope to both health care providers and an increasingly diverse elderly population that continues to grow. “It’s possible that giving people of all ages good access to care will reverse the health disparities we see. But there may be other reasons behind these disparities. We need to do more research to know for sure,” Tan said.

Additional authors on the study include senior author, Kenneth E. Covinsky, MD, MPH, UCSF assistant professor of medicine and SFVAMC staff physician; Li-Yung Lui, MA, MS, UCSF department of medicine; Catherine Eng, MD, UCSF clinical professor and medical director, On Lok Senior Health Services, San Francisco, California; Ashish K. Jha, MD, Brigham and Women’s Hospital and Harvard Medical School.

Tan was supported in part by the VA National Quality Scholars Fellowship Program, a T-32 Training in Geriatric Medicine Grant, and a Geriatric Academic Career Award from the Health Resources and Services Administration of the Department of Health and Human Services.

Covinsky was supported in part by an Independent Scientist Award from the Agency for Healthcare Research and Quality and is a Paul Beeson Faculty Scholar in Aging Research.