Racial Disparities in Chronic Conditions Outcomes in Primary Care Settings: Between- Versus Within-Practice Differences

Racial disparities in chronic condition management lead to adverse outcomes such as increased emergency department (ED) visits and hospitalizations among minority patients. These disparities may arise from differences within or between primary care practices, but limited research has explored these disparities. To examine racial/ethnic disparities in chronic condition outcomes in primary care and determine if they are due to between- versus within-practice differences. We analyzed 2018 Medicare claims data for beneficiaries visiting primary care practices during 2018 to 2019. We used logistic regression models to assess racial and ethnic disparities in outcomes and the contribution of between- versus within- practice differences to the disparities. 1033 primary care practices in Arizona, California, New Jersey, Pennsylvania, Texas, and Washington. Medicare beneficiaries aged 65+ with one of the chronic conditions attributed to primary care practices. All-cause ED visits, ambulatory care sensitive (ACS) ED visits, and all-cause hospitalizations among older adults with specific chronic conditions (asthma, chronic obstructive pulmonary disease, hypertension, congestive heart failure, cardiovascular disease, and diabetes). Black patients were more likely to experience ED visits (Predicted probability: .371, 95% Confidence Interval (CI): 0.362-0.380), and ACS ED visits (Predicted probability: .248, CI: 0.241-0.256) but less likely to experience hospitalizations (Predicted probability: .124, CI: 0.116-0.133), compared to White patients. Hispanic patients showed similar trends in ED visits (Predicted probability: .357, CI: 0.350-0.365) and ACS ED visits (Predicted probability: .233, CI: 0.227-0.239). Minority patients were clustered within a small number of practices (Black: 50% in 6% of practices, Hispanic: 50% in 8% of practices). Disparities in ED visits and hospitalizations were largely explained by within-practice differences. As disparities primarily originate from within-practice differences, addressing racial and ethnic disparities requires improving care quality across all practices rather than targeting those with high proportions of minorities.