Disparities in Preventable Hospitalization Among Patients With Alzheimer Diseases

  • Jie Chen
    Address correspondence to: Jie Chen, PhD, Department of Health Policy and Management, Hospital And Public health interdisciPlinarY research (HAPPY) Lab, School of Public Health, University of Maryland, 3310E School of Public Health Building, 4200 Valley Drive, College Park MD 20742.
    Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, Maryland

    Hospital And Public health interdisciPlinarY research (HAPPY) Lab, School of Public Health, University of Maryland, College Park, Maryland
    Search for articles by this author
  • Ivy Benjenk
    Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, Maryland

    Hospital And Public health interdisciPlinarY research (HAPPY) Lab, School of Public Health, University of Maryland, College Park, Maryland
    Search for articles by this author
  • Deanna Barath
    Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, Maryland

    Hospital And Public health interdisciPlinarY research (HAPPY) Lab, School of Public Health, University of Maryland, College Park, Maryland
    Search for articles by this author
  • Andrew C. Anderson
    Department of Health Policy & Management, Tulane School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana
    Search for articles by this author
  • Charles F. Reynolds III
    Department of Behavioral and Community Health Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
    Search for articles by this author


      System-level care coordination strategies can be the most effective to promote continuity of care among people with Alzheimer's disease; however, the evidence is lacking. The objective of this study is to determine whether accountable care organizations are associated with lower rates of potentially preventable hospitalizations for people with Alzheimer's disease and whether hospital accountable care organization affiliation is associated with reduced racial and ethnic disparities in preventable hospitalizations among patients with Alzheimer's disease.


      This study employed a cross-sectional study design and used 2015 Healthcare Cost and Utilization Project inpatient claims data from 11 states and the 2015 American Hospital Association Annual Survey. Logistic regression and the Blinder–Oaxaca decomposition method were used.


      African American patients with Alzheimer's disease were less likely to be hospitalized at accountable care organization‒affiliated hospitals than White patients. Among patients with Alzheimer's disease who were hospitalized, hospital accountable care organization affiliation was associated with lower odds of potentially preventable hospitalizations (OR=0.86, p=0.02; OR=0.66, p<0.001 with propensity score matching) after controlling for patient characteristics, hospital characteristics, and state indicators. Hospital accountable care organization affiliation explained 3.01% (p<0.01) of the disparity in potentially preventable hospitalizations between White and African American patients but could not explain disparities between White and Latinx patients.


      Evidence suggests that accountable care organizations may be able to improve care coordination for people with Alzheimer's disease and to reduce disparities between Whites and African Americans. Further research is needed to determine whether this benefit can be attributed to accountable care organization formation or whether providers that participate in accountable care organizations tend to provide higher-quality care.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Beach SR
        • Schulz R
        • Friedman EM
        • Rodakowski J
        • Martsolf RG
        • James AE.
        Adverse consequences of unmet needs for care in high-need/high-cost older adults.
        J Gerontol B Psychol Sci Soc Sci. 2020; 75: 459-470
        • Lin PJ
        • Fillit HM
        • Cohen JT
        • Neumann PJ.
        Potentially avoidable hospitalizations among Medicare beneficiaries with Alzheimer's disease and related disorders.
        Alzheimers Dement. 2013; 9: 30-38
        • Davydow DS
        • Zivin K
        • Katon WJ
        • et al.
        Neuropsychiatric disorders and potentially preventable hospitalizations in a prospective cohort study of older Americans.
        J Gen Intern Med. 2014; 29: 1362-1371
        • Bynum JP
        • Rabins PV
        • Weller W
        • Niefeld M
        • Anderson GF
        • Wu AW.
        The relationship between a dementia diagnosis, chronic illness, Medicare expenditures, and hospital use.
        J Am Geriatr Soc. 2004; 52: 187-194
        • Alzheimer's Association
        2018 Alzheimer's disease facts and figures.
        Alzheimers Dement. 2018; 14: 367-429
        • Desai U
        • Kirson NY
        • Ye W
        • Mehta NR
        • Wen J
        • Andrews JS.
        Trends in health service use and potentially avoidable hospitalizations before Alzheimer's disease diagnosis: a matched, retrospective study of U.S. Medicare beneficiaries.
        Alzheimers Dement (Amst). 2019; 11: 125-135
        • Moy E
        • Chang E
        • Barrett M
        Centers for Disease Control and Prevention. Potentially preventable hospitalizations—United States, 2001-2009.
        MMWR Suppl. 2013; 62: 139-143
        • Geronimus AT
        • Hicken M
        • Keene D
        • Bound J.
        Weathering” and age patterns of allostatic load scores among blacks and whites in the United States.
        Am J Public Health. 2006; 96: 826-833
        • Black BS
        • Johnston D
        • Rabins PV
        • Morrison A
        • Lyketsos C
        • Samus QM.
        Unmet needs of community-residing persons with dementia and their informal caregivers: findings from the maximizing independence at home study.
        J Am Geriatr Soc. 2013; 61: 2087-2095
        • Lines L
        • Sherif N
        • Wiener J.
        Racial and ethnic disparities among individuals with Alzheimer's disease in the United States: a literature review.
        RTI Press, 2014 (RR-0024-1412)
        • Dementias, including Alzheimer's disease
        Healthy People 2020., Office of Disease Prevention and Health Promotion, 2020 ( Updated October 10, 2020. Accessed January 14, 2021)
        • Downer B
        • Al Snih S
        • Raji M
        • et al.
        Healthcare utilization of Mexican-American Medicare beneficiaries with and without Alzheimer's disease and related dementias.
        PLoS One. 2020; 15e0227681
        • Bass DM
        • Judge KS
        • Maslow K
        • et al.
        Impact of the care coordination program “Partners in Dementia Care” on veterans’ hospital admissions and emergency department visits.
        Alzheimers Dement (N Y). 2015; 1: 13-22
        • Bass DM
        • Judge KS
        • Snow AL
        • et al.
        A controlled trial of Partners in Dementia Care: veteran outcomes after six and twelve months.
        Alzheimers Res Ther. 2014; 6: 9
        • French DD
        • LaMantia MA
        • Livin LR
        • Herceg D
        • Alder CA
        • Boustani MA.
        Healthy Aging Brain Center improved care coordination and produced net savings.
        Health Aff (Millwood). 2014; 33: 613-618
        • Burwell SM.
        Setting value-based payment goals–HHS efforts to improve U.S. health care.
        N Engl J Med. 2015; 372: 897-899
        • Berwick DM.
        Making good on ACOs’ promise–the final rule for the Medicare Shared Savings Program.
        N Engl J Med. 2011; 365: 1753-1756
        • Anderson AC
        • Chen J.
        ACO affiliated hospitals increase implementation of care coordination strategies.
        Med Care. 2019; 57: 300-304
        • Briggs ADM
        • Fraze TK
        • Glick AL
        • Beidler LB
        • Shortell SM
        • Fisher ES.
        How do accountable care organizations deliver preventive care services? A mixed-methods study.
        J Gen Intern Med. 2019; 34: 2451-2459
        • Winblad U
        • Mor V
        • McHugh JP
        • Rahman M.
        ACO-affiliated hospitals reduced rehospitalizations from skilled nursing facilities faster than other hospitals.
        Health Aff (Project Hope). 2017; 36: 67-73
        • Fraze T
        • Lewis VA
        • Rodriguez HP
        • Fisher ES.
        Housing, transportation, and food: how ACOs seek to improve population health by addressing nonmedical needs of patients.
        Health Aff (Millwood). 2016; 35: 2109-2115
        • Fraze TK
        • Beidler LB
        • Briggs ADM
        • Colla CH.
        ‘Eyes in the home’: ACOs use home visits to improve care management, identify needs, and reduce hospital use.
        Health Aff (Millwood). 2019; 38: 1021-1027
        • Lewis VA
        • Schoenherr K
        • Fraze T
        • Cunningham A.
        Clinical coordination in accountable care organizations: a qualitative study.
        Health Care Manage Rev. 2019; 44: 127-136
        • McWilliams JM
        • Hatfield LA
        • Chernew ME
        • Landon BE
        • Schwartz AL.
        Early performance of accountable care organizations in Medicare.
        N Engl J Med. 2016; 374: 2357-2366
        • Chukmaitov A
        • Harless DW
        • Bazzoli GJ
        • Muhlestein DB.
        Preventable hospital admissions and 30-day all-cause readmissions: does hospital participation in accountable care organizations improve quality of care?.
        Am J Med Qual. 2019; 34: 14-22
        • Ouayogodé MH
        • Mainor AJ
        • Meara E
        • Bynum JPW
        • Colla CH
        Association between care management and outcomes among patients with complex needs in Medicare accountable care organizations.
        JAMA Netw Open. 2019; 2e196939
        • Colla CH
        • Lewis VA
        • Kao LS
        • O'Malley AJ
        • Chang CH
        • Fisher ES
        Association between Medicare accountable care organization implementation and spending among clinically vulnerable beneficiaries.
        JAMA Intern Med. 2016; 176: 1167-1175
        • Werner RM
        • Kanter GP
        • Polsky D.
        Association of physician group participation in accountable care organizations with patient social and clinical characteristics.
        JAMA Netw Open. 2019; 2e187220
        • Lewis VA
        • Fisher ES
        • Colla CH.
        ACOs and disparities: the authors reply.
        Health Aff (Millwood). 2017; 36: 960
        • Lewis VA
        • Fraze T
        • Fisher ES
        • Shortell SM
        • Colla CH.
        ACOs serving high proportions of racial and ethnic minorities lag in quality performance.
        Health Aff (Millwood). 2017; 36: 57-66
        • Navathe AS
        • Bain AM
        • Werner RM.
        Do changes in post-acute care use at hospitals participating in an accountable care organization spillover to all Medicare beneficiaries?.
        J Gen Intern Med. 2018; 33: 831-838
        • Fisk M.
        Health care as a public good.
        J Soc Philos. 1996; 27: 14-40
        • Healthcare Cost and Utilization Project (HCUP)
        Overview of the State Inpatient Databases (SID).
        Agency for Healthcare Research and Quality, Rockville, MD2015 ( Published 2015. Accessed October 22, 2018)
      1. American Hospital Association (AHA). AHA Annual Survey Database, 2015. Accessed July 12, 2019

      2. Chronic Conditions Data Warehouse. CCW Chronic Condition Algorithms. Centers for Medicare & Medicaid Services. Accessed July 12, 2019.

        • Agency for Healthcare Research and Quality
        Prevention Quality Indicators Technical Specifications Updates Version v2018 and v2018.0.1 (ICD 10-CM/PCS).
        Agency for Healthcare Research and Quality, Rockville, MD2018 ( Published 2018. Accessed October 15, 2018)
        • Westrick E
        • Kogut S.
        Medicare Ambulatory Care Indicators for the Elderly: Refinement of the Access to Care for the Elderly Project Indicators: Final Report.
        MedPAC, Washington, DC2006
        • Hackbarth GM
        • Christianson J
        • Miller ME.
        Report to the Congress: Medicare and the Health Care Delivery System.
        Medicare Payment Advisory Commission, Washington, DCJune 15, 2015 ( Published une 15, 2015. Accessed April 23, 2020)
        • Feng Z
        • Silver BC
        • Segelman MD
        • et al.
        Developing risk-adjusted avoidable hospitalizations and emergency department visits quality measures: a report by staff from RTI International for the Medicare Payment Advisory Commission.
        MedPAC, Washington, DCAugust 2019 ( Published August 2019. Accessed April 23, 2020)
        • Niles J
        • Litton T
        • Mechanic R.
        An initial assessment of initiatives to improve care for high-need, high-cost individuals in accountable care organizations.
        Health Affairs Blog. 2019; ( Accessed March 9, 2020)
        • Colla CH
        • Lewis VA
        • Tierney E
        • Muhlestein DB.
        Hospitals participating in ACOs tend to be large and urban, allowing access to capital and data.
        Health Aff (Millwood). 2016; 35: 431-439
        • Barath D
        • Amaize A
        • Chen J.
        Accountable care organizations and preventable hospitalizations among patients with depression.
        Am J Prev Med. 2020; 59: e1-e10
        • Leuven E
        • Sianesi B.
        PSMATCH2: Stata module to perform full Mahalanobis and propensity score matching, common support graphing, and covariate imbalance testing. Statistical Software Components S432001.
        Boston College Department of Economics, 2003 ( Updated February 1, 2018. Accessed September 26, 2020)
        • Stuart EA
        • Huskamp HA
        • Duckworth K
        • et al.
        Using propensity scores in difference-in-differences models to estimate the effects of a policy change.
        Health Serv Outcomes Res Methodol. 2014; 14: 166-182
        • Fairlie RW.
        An extension of the Blinder-Oaxaca decomposition technique to logit and probit models.
        J Econ Soc Meas. 2005; 30: 305-316
        • Oaxaca RL
        • Ransom MR.
        Identification in detailed wage decompositions.
        Rev Econ Stat. 1999; 81: 154-157
      3. What is Alzheimer's disease? Alzheimer's Association. Updated September 4, 2020. Accessed September 26, 2020.

        • McWilliams JM
        • Chernew ME
        • Landon BE.
        Medicare ACO program savings not tied to preventable hospitalizations or concentrated among high-risk patients.
        Health Aff (Millwood). 2017; 36: 2085-2093
        • Bleser WK
        • Muhlestein D
        • Saunders RS
        • McClellan MB.
        Half a decade in, Medicare accountable care organizations are generating net savings: part 1.
        Health Affairs Blog, September 20, 2018 ( Accessed November 20, 2019)
        • Yasaitis LC
        • Pajerowski W
        • Polsky D
        • Werner RM.
        Physicians’ participation in ACOs is lower in places with vulnerable populations than in more affluent communities.
        Health Aff (Millwood). 2016; 35: 1382-1390
        • Markovitz AA
        • Hollingsworth JM
        • Ayanian JZ
        • et al.
        Risk adjustment in Medicare ACO program deters coding increases but may lead ACOs to drop high-risk beneficiaries.
        Health Aff (Millwood). 2019; 38: 253-261
        • Epstein AM
        • Jha AK
        • Orav EJ
        • et al.
        Analysis of early accountable care organizations defines patient, structural, cost, and quality-of-care characteristics.
        Health Aff (Millwood). 2014; 33: 95-102
        • Franzini L
        • Ribble JC
        • Keddie AM.
        Understanding the Hispanic paradox.
        Ethn Dis. 2001; 11: 496-518
        • Jha AK
        • Orav EJ
        • Zheng J
        • Epstein AM.
        The characteristics and performance of hospitals that care for elderly Hispanic Americans.
        Health Aff (Millwood). 2008; 27: 528-537
        • Falster MO
        • Jorm LR
        • Douglas KA
        • Blyth FM
        • Elliott RF
        • Leyland AH.
        Sociodemographic and health characteristics, rather than primary care supply, are major drivers of geographic variation in preventable hospitalizations in Australia.
        Med Care. 2015; 53: 436-445
        • Phelan JC
        • Link BG.
        Is racism a fundamental cause of inequalities in health?.
        Annu Rev Sociol. 2015; 41: 311-330
        • Sen AP
        • Chen LM
        • Wong Samson L
        • Epstein AM
        • Joynt Maddox KE
        Performance in the Medicare Shared Savings Program by accountable care organizations disproportionately serving dual and disabled populations.
        Med Care. 2018; 56: 805-811
        • Chen J
        • DuGoff EH
        • Novak P
        • Wang MQ.
        Variation of hospital-based adoption of care coordination services by community-level social determinants of health.
        Health Care Manage Rev. 2020; 45: 332-341
        • Zhu X
        • Ullrich F
        • Huang H
        • Mueller KJ.
        Rural hospital participation in Medicare accountable care organizations.
        Policy Brief No. 2020-1. RUPRI Center for Rural Health Policy Analysis, April 2020 (Published April 2020. Accessed April 21, 2020)
        • O'Malley AS
        • Rich EC
        • Sarwar R
        • et al.
        How accountable care organizations use population segmentation to care for high-need, high-cost patients.
        The Commonwealth Fund, New York, NYJanuary 3, 2019 (Published)

      Linked Article