Original researchRacial and Ethnic Disparities in Alzheimer's Disease Pharmacotherapy Exposure: An Analysis Across Four State Medicaid Populations
Introduction
Alzheimer's disease (AD) is the most common form of dementia, accounting for 60% to 80% of cases.1 AD is a nonreversible, progressive dementia manifested by gradual deterioration in cognition and behavioral disturbances.2 There are approximately 24 million individuals worldwide and as many as 5.3 million Americans who are living with AD. It is the sixth leading cause of death in the United States and the fifth leading cause of death among those 65 years of age and older.1 By 2050, the incidence of AD is expected to approach nearly 1 million people per year, with a total estimated prevalence of 11 to 16 million persons.1
Treatment of AD involves both pharmacologic and nonpharmacologic treatments. The U.S. Food and Drug Administration (FDA) has approved 2 classes of medications for the treatment of AD: cholinesterase inhibitors (ChEIs) (donepezil, rivastigmine, galantamine, tacrine) and an N-methyl-d-aspartate receptor antagonist (memantine). The main focus of drug treatment for AD is to improve cognitive function, such as memory and thinking, and to slow the progression of symptoms. Most evidence relating to pharmacologic treatments of AD (eg, donepezil, galantamine, rivastigmine, tacrine, and memantine) have demonstrated statistically significant improvements in clinicians' and caregivers' global assessments and in slowing the rate of decline in cognition.3, 4, 5, 6, 7
The issue of treatment disparities in AD has received little attention. Mehta et al8 conducted a study examining ethnic differences in ChEI use for patients with Alzheimer's and found that African Americans were significantly less likely (OR = 0.6; 95% CI, 0.4–0.9) to be taking a ChEI compared with whites, whereas no significant differences were found in ChEI use when comparing whites with Hispanics (OR = 0.9; 95% CI, 0.7–1.1) and Asian Americans (OR = 0.7; 95% CI, 0.5–1.0). Another study examining memantine use found that whites were significantly more likely (OR = 6.47; 95% CI, 1.25–33.39) to use memantine compared with African Americans.9 Research has shown that minority Medicare beneficiaries use fewer medications and spend less on prescription medications.10 Gaskin et al10 found that black and Hispanic Medicare beneficiaries had lower total spending and out-of-pocket spending annually ($330.10 and $343.60, respectively), both significantly less than for whites ($473.80). Zuckerman et al11 found similar results in that non-Hispanic blacks and non-Hispanic others were significantly less likely (OR = 0.75; 95% CI, 0.57–0.99) and (OR = 0.50; 95% CI, 0.26–0.96, respectively), to be using an antidementia medication compared with non-Hispanic whites in a sample of Medicare beneficiaries with dementia.
A study by Poon et al12 of antihypertensive and dementia medications found that African Americans were less likely than whites to receive angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), β-blockers, acetyl CHeI, and memantine (P < 0.05). Hispanics were more likely than whites to be prescribed an ACE inhibitor but less likely to be prescribed an ARB, β-blocker, nondihydropyridine calcium-channel blocker, loop diuretic, α-agonist, or potassium-sparing diuretics (P < 0.05).12
Several studies have found how knowledge and attitudes about AD contribute to family decision making about symptoms, diagnosis, treatment, and participation in research.13, 14, 15, 16, 17, 18, 19 Connell et al20 examined racial/ethnic differences in knowledge and beliefs about AD and its risk factors and treatment options and found that whites versus minorities differed in the following areas: (1) knowledge about the disease; (2) concern about AD; (3) beliefs about putative causes of AD; and (4) beliefs about the effectiveness of various options for reducing risk of and treating AD. In addition, other factors to medication access for minorities include insurance adequacy, pharmacy access to a ChEI or memantine, and availability and adequacy of dementia assessment resources, including reduced access to primary care physicians (PCPs) and specialists.21 The complex interactions between race, ethnicity, lifestyle, and environmental factors require that future studies of AD in specific racial or ethnic groups attend to measures of educating and increasing awareness of AD.
With the relatively high number of individuals on Medicaid (most of those consisting of minorities, women, and the elderly), examining whether treatment disparities exist in individuals with AD is an important health policy issue, so that attempts can be made to improve patient care and access and potentially help reduce costs. The purpose of this study was to determine whether an association existed between race/ethnicity and exposure to AD pharmacotherapy, while controlling for demographic characteristics and resource utilization factors across 4 state Medicaid populations with AD.
Section snippets
Methods
This research was an observational retrospective study using Medicaid and Medicare administrative data from California, Florida, New Jersey, and New York. The data for this study were obtained from the Medicaid Analytic extract File (MAX) from the Centers for Medicare and Medicaid Services (CMS). MAX is a person-level data file on Medicaid eligibility, service utilization, and payment information for all individuals. MAX consists of 1 personal summary file and 4 claims files, which include
Results
Table I displays basic demographic information for the study population. A total of 158,974 individuals were identified for inclusion, with all persons being eligible for both Medicare and Medicaid. Approximately 72.5% of the study sample was female and 55.7% were non-Hispanic white. Approximately 33.4% of individuals in this study resided in California. Almost half (45.6%) received 1 or more prescriptions for donepezil. Most individuals (66.6%) were exposed to only 1 ChEI or memantine. The
Discussion
The primary objective of this study was to determine whether a difference existed between AD pharmacotherapy exposure across racial/ethnic groups. When adjusting for covariates in this analysis, non-Hispanic blacks were less likely than non-Hispanic whites to be exposed to medication therapy (P < 0.0001). These results are consistent with those of a study conducted by Hernandez et al, 21 in which non-Hispanic blacks were less likely to receive ChEIs (OR = 0.59; 95% CI, 0.46–0.76) or memantine
Conclusions
Disparities in AD pharmacotherapy exposure among minority populations were just as prevalent, if not greater, than minority/white disparities. Hispanics and persons with ethnicity classified as other were significantly more likely to be exposed to AD pharmacotherapy compared with blacks. Furthermore, geographic location was an important predictor of treatment disparities, with California having the most prevalent amount of disparities across racial/ethnic groups. Future research examining
Conflicts of Interest
The authors have indicated that they have no conflicts of interest regarding the content of this article.
Acknowledgments
Ms. Gilligan contributed to the study design, data analysis, data interpretation, and drafting of the initial version of the manuscript. Dr. Malone contributed to the study design, data acquisition, data interpretation, writing, review, and revisions of the manuscript. Dr. Warholak contributed to the study design, interpretation of findings, writing, review, and revisions of manuscript. Dr. Armstrong contributed to the study design, interpretation of findings, writing, review, and revisions of
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