Only 1 in 5 patients have timely dementia diagnosis, California study suggests

Black, Asian, and Hispanic Medicare beneficiaries were less likely than White beneficiaries to receive a timely diagnosis of mild cognitive impairment (MCI), a retrospective California study found — and, researchers added, older Asian adults also were less likely to have a comprehensive dementia workup than older White adults.

“These findings highlight substantial disparities in the timeliness and comprehensiveness of dementia diagnosis,” wrote Katherine Possin, PhD, of the University of California, San Francisco, and co-authors in JAMA Neurology. “Public health interventions are needed to achieve equitable care for people living with dementia across all racial/ethnic groups.”

Possin and colleagues used 2013-2015 California Medicare fee-for-service data from 10,472 older adults who were continuously enrolled in Medicare Parts A and B. All participants had no diagnosis of dementia or mild cognitive impairment in 2013-2014 and were diagnosed with incident dementia or mild cognitive impairment from January-June 2015. Participants had a mean age of about 83 years and 62.1% were female; 9.5% were Asian, 3.9% were Black, 12.0% were Hispanic, and 74.6% were White.

The researchers defined timeliness as receiving a diagnosis of MCI prior to a dementia diagnosis. Comprehensiveness of diagnostic workups was assessed by claims for specialty referral, neuroimaging tests, and laboratory evaluations (vitamin B12 and thyroid function studies) within six months before or after the incident diagnosis. Recommended workup components were identified from published sources, including American Academy of Neurology guidelines.

Compared with White beneficiaries, adjusted ORs for timeliness of diagnosis were 0.45 (95% CI 0.37-0.55) for Asian, 0.70 (95% CI 0.53-0.91) for Black, and 0.65 (95% CI, 0.55-0.77) for Hispanic beneficiaries. Older age (OR for each additional five years: 0.80, 95% CI 0.77-0.82, P<0.001), residence in a highly disadvantaged neighborhood (OR 0.73; 95% CI 0.63-0.84; P<0.001), and greater comorbidity (OR for each added condition: 0.96, 95% CI 0.94-0.98, P<0.001) also reduced the likelihood of incident diagnosis of MCI rather than dementia.

Adjusted analysis showed Asian Medicare beneficiaries were less likely to receive recommended diagnostic workup services than those who were White (IRR 0.81, 95% CI 0.74-0.87, P<0.001). Findings remained significant after adjustment for age, sex, comorbidities, neighborhood disadvantage, and rurality.

“Although not surprising, these results underscore the pressing need in the United States to address ethnic and racial healthcare disparities, particularly among elderly individuals, the fastest growing segment of the population and the leading consumers of health care,” wrote Claudia Kawas, MD, of the University of California, Irvine, and co-authors, in an accompanying editorial.

Previous Medicare studies found that White adults were more likely to receive anti-dementia medications than adults in other ethnic or racial groups, with differences persisting after accounting for socioeconomic factors, health care access and utilization, and comorbidities, the editorialists observed.

“A major challenge to our understanding of dementia care is the absence of diversity in study populations engaged in research,” they added. “Most of what we know today about risk and protective factors for dementia, treatment effects, and biomarkers related to cognitive impairment is derived from highly educated, urban dwelling, non-Hispanic White individuals. Recruiting diverse populations into research requires directed resources to cultivate trust and engage with different communities.”

Overall, only 21.2% of Medicare beneficiaries in the study received a timely diagnosis according to their criterion, Possin and colleagues wrote. Components of the workup were received by a minority of patients, with 34.6% receiving specialist evaluation, 16.2% laboratory testing, and 28.7% neuroimaging.

The frequent lack of workup in patients of all groups was “perhaps more surprising than the observed disparities,” the editorialists noted. “Physicians must be made aware of the disproportionate effect of dementia in underrepresented and diverse communities and fully recognize the biases of the medical establishment in the diagnosis and care of these underserved individuals,” they wrote. “Physician education and outreach will be an essential component to address these issues and to improve health care delivery to the most vulnerable populations. It is a challenge we all must address.”

“Although our primary findings concern racial/ethnic disparities in dementia diagnosis, our results also provide important insights into overall dementia diagnostic practices in California,” Possin and co-authors pointed out. “Moreover, our analyses revealed that these services were less likely to be performed for individuals who were older and had a greater comorbidity burden, which underlines the importance of supporting efforts to optimize dementia diagnostic pathways, particularly in general practice settings.”

Limitations include the use of secondary claims data for diagnosis, that dministrative race and ethnicity data may be inaccurate in this setting, and that the study population consisted entirely of Medicare fee-for-service beneficiaries in California, which may limit generalizability.

  1. Black, Asian, and Hispanic Medicare beneficiaries were less likely than White beneficiaries to receive a diagnosis of mild cognitive impairment (MCI) versus one of dementia, a retrospective California study found.

  2. Overall, only 21.2% of Medicare beneficiaries in the study received a timely diagnosis, according to the researchers’ criterion.

Paul Smyth, MD, Contributing Writer, BreakingMED™

This study was supported by the Department of Health and Human Services Centers for Medicare & Medicaid Services, the National Institute of Neurological Disorders and Stroke, the National Institute on Aging, and the Global Brain Health Institute.

Possin reported receiving grants from the National Institute on Aging and the National Institute of Neurological Disorders and Stroke during the conduct of the study; grants from Global Brain Health Institute, Quest Diagnostics, Administration for Community Living, Rainwater Charitable Trust, and Merck Foundation outside the submitted work; and personal fees from ClearView Health Partners and Vanguard.

The editorial was supported by the National Institutes of Health.

Kawas is supported by the National Institutes of Health.

Cat ID: 130

Topic ID: 82,130,404,494,730,130,361,192,255,925

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