JAMA Health Forum最新文献

Importance: Evidence is limited regarding whether end-of-life care for individuals with dementia varies by race and ethnicity, and whether observed variations can be explained by differences in the physicians providing their care.

Objective: To evaluate end-of-life care among individuals with dementia across racial and ethnic groups, and to investigate whether care variations are explained by differences in treating physicians.

Design, setting, and participants: This cohort study used national, population-based claims data from a 20% random sample of Medicare fee-for-service beneficiaries aged 66 years or older with a diagnosis of dementia who died between 2016 and 2019. Data were analyzed from January 2024 to June 2025.

Main outcomes and measures: Emergency department, hospital, and intensive care unit use, mechanical ventilation or cardiopulmonary resuscitation, and feeding tube placement in last 30 days of life; death in acute care hospital; hospice use and palliative care counseling in last 180 days of life; and any billed advance care planning before death.

Results: Among 259 945 decedents with dementia (mean [SD] age, 85.8 [8.0] years; 60.4% female), 8.3% were non-Hispanic Black, 4.4% were Hispanic, and 87.3% were non-Hispanic White. Compared with non-Hispanic White decedents, non-Hispanic Black decedents were more likely to receive emergency department (difference, 5.7 percentage points [pp]; 95% CI, 5.0-6.4 pp), hospital (difference, 4.0 pp; 95% CI, 3.3-4.7 pp), intensive care unit (difference, 4.3 pp; 95% CI, 3.7-4.9 pp), mechanical ventilation or cardiopulmonary resuscitation (difference, 3.8 pp; 95% CI, 3.3-4.3 pp), and feeding tube placement (difference, 1.8 pp; 95% CI, 1.5-2.1 pp) care, as well as die in a hospital (difference, 3.5 pp; 95% CI, 2.9-4.1 pp). Non-Hispanic Black decedents were less likely to use hospice (difference, -6.1 pp; 95% CI, -6.8 to -5.4 pp) and more likely to receive palliative care counseling (difference, 3.2 pp; 95% CI, 2.6-3.9 pp) and billed advance care planning (difference, 1.8 pp; 95% CI, 1.2-2.3 pp) than non-Hispanic White decedents. Similar patterns were observed among Hispanic decedents. Variations in end-of-life care remained qualitatively unchanged when comparing decedents treated by the same physician.

Conclusions and relevance: Findings from this cohort study suggest that non-Hispanic Black and Hispanic decedents with dementia received more intensive end-of-life care despite higher rates of billed advance care planning and palliative care counseling than non-Hispanic White decedents. Observed racial and ethnic variations were not explained by differences in the physicians treating them.

Importance: Dentists' limited participation in Medicaid is a substantial barrier to addressing the persistent unmet need for dental care among adult Medicaid beneficiaries.

Objective: To assess dentists' experiences and perceptions regarding Medicaid and to identify barriers and facilitators to participation as well as strategies to improve dentists' participation and service delivery.

Design, setting, and participants: This qualitative study involved semistructured individual interviews of dentists from 8 states (Maryland, Massachusetts, Michigan, New York, North Carolina, South Dakota, Wisconsin, Wyoming) about their experiences with and perceptions of Medicaid. The study was conducted between August 2022 and July 2023. Data were analyzed from September 2023 to September 2024.

Main outcomes and measures: Themes related to Medicaid participation were identified through thematic analysis, and descriptive statistics were used to characterize the sample.

Results: Of the 67 dentists interviewed, 46 (68.6%) accepted Medicaid, and 21 (31.3%) did not accept Medicaid. The sample consisted of 36 females (53.7%) and 31 males (46.3%), with a mean (SD) age of 45.1 (14.4) years and a mean (SD) of 16.4 (13.8) years of work experience. Three key domains affecting dentists' participation in Medicaid were identified: system-level, dentist-level, and patient-level factors. At the system-level domain, barriers to Medicaid acceptance, including low reimbursement rates, administrative burdens, restrictive benefit designs, and poor communication about benefits, played a role in perceived inefficiencies and limited dentists' engagement. Challenges at the dentist-level domain included language barriers, capacity constraints, stigma surrounding Medicaid, and concerns about financial sustainability. Factors at the patient level, including appointment adherence, unfavorable perceptions of preventive care, logistical barriers, and limited oral health literacy, had a potential role in limiting effective care delivery. Dentists who accepted Medicaid reported frustration with administrative inefficiencies and reimbursement rates, whereas those who did not participate in Medicaid emphasized financial stability concerns.

Conclusions and relevance: This study highlights the complex interplay of barriers and facilitators at system, dentist, and patient levels that impact oral health care delivery to adult Medicaid beneficiaries. Increasing reimbursement rates is important but should be complemented by efforts to streamline administrative processes, improve patient engagement, and support dentists through targeted incentive programs.