A Geographic Analysis of Racial Disparities in Use of Pulmonary Rehabilitation After Hospitalization for COPD Exacerbation

Abstract

Background: Guidelines recommend pulmonary rehabilitation (PR) after hospitalization for an exacerbation of COPD, but few patients enroll in PR. We explored whether density of PR programs explained regional variation and racial disparities in receipt of PR.

Methods: We used Centers for Medicare & Medicaid Services data from 223,832 Medicare beneficiaries hospitalized for COPD during 2012 who were eligible for PR postdischarge. We used Hospital-Referral Regions (HRR) as the unit of analysis. For each HRR, we calculated the density of PR programs as a measure of program access and estimated risk-standardized rates of PR within 6 months of discharge overall, and for non-Hispanic, white, and black beneficiaries. We used linear regression to examine the relationship between access to PR and HRR PR rates. We tested for racial disparity in PR rates among non-Hispanic white and black beneficiaries living in the same HRRs.

Results: Across 306 HRRs, the median number of PR programs per 1,000 Medicare beneficiaries was 0.06 (interquartile range [IQR], 0.04-0.10). Risk-standardized rates of PR ranged from 0.53% to 6.67% (median, 1.93%). Density of PR programs was positively associated with PR rates overall and among non-Hispanic white beneficiaries (P < .001), but this relationship was not observed among black beneficiaries. Rates were higher among non-Hispanic white beneficiaries (median, 2.08%; IQR, 1.54%-2.87%) compared with black beneficiaries (median, 1.19%; IQR, 1.15%-1.20%).

Conclusions: Greater PR program density was associated with higher rates of PR for non-Hispanic white but not black beneficiaries. Further research is needed to identify reasons for this discrepancy and strategies to increase receipt of PR for black patients.

Keywords: Medicare; geographic analysis; pulmonary disease, chronic obstructive; pulmonary rehabilitation; racial disparties.

Figure 1

A, PR programs per 1,000 Medicare FFS beneficiaries by HRR for 2012. B, Risk-standardized PR rates for by HRR for 2012. Source: Authors’ calculations on the basis of Centers for Medicare & Medicaid Services public use files and fee-for-service files. Note: Risk-standardized rates are adjusted for age, sex, comorbidity burden, admissions during prior year, current tobacco use, and Medicaid dual eligibility. HRR = hospital referral region; PR = pulmonary rehabilitation.

Figure 2

A, Risk-standardized rate of PR posthospitalization, non-Hispanic white Medicare beneficiaries, by HRR for 2012. B, Risk-standardized rate of PR posthospitalization, black Medicare beneficiaries, by HRR for 2012. Source: Authors’ calculations on the basis of Centers for Medicare & Medicaid Services public use files and fee-for-service files. Note: Risk-standardized rates are adjusted for age, sex, comorbidity burden, admissions during prior year, current tobacco use, and Medicaid dual eligibility. See Figure 1 legend for expansion of abbreviations.

Figure 3

2012 risk-standardized PR rates, by HRR PR program density. Note: A total of 306 HRRs were divided into tertiles on the basis of PR program density; HRRs were then excluded, with less than 2.5% black Medicare fee-for-service beneficiaries. Risk-standardized rates are adjusted for age, sex, comorbidity burden, admissions during prior year, current tobacco use, and Medicaid dual eligibility. Program density is the number of PR programs divided by 1,000 Medicare FFS beneficiaries older than age 65 per HRR: Low was defined as 0 to 0.047 providers/1,000 Medicare FFS beneficiaries; moderate as 0.048 to 0.088; and high as 0.088 to 0.280. See Figure 1 legend for expansion of abbreviations.