Unequal Utilization of New
Technologies by Race
The Use of New Prostate Surgeries (TUNA and TUMT)
among Medicare Elderly Beneficiaries
Xinhua Yu, PhD, MBBS
A. Marshall McBean, MD, MSc
Debra S. Caldwell, MS
Research Data Assistance Center
University of Minnesota
Janet A. Anderson
Centers for Medicare and Medicaid Services
AcademyHealth Annual Research Meeting
June 7, 2004
Benign Prostate Hypertrophy (BPH)
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Enlargement of prostate gland
Enlargement causes obstruction of outflow of
urine and results in symptoms that
significantly affect the quality of life
BPH affects three out of four men aged 70 or
above
The prevalence of BPH for Blacks and Whites
is not significantly different (Platz EA, Urology 59,
2002)
Treatment
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Surgical:
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transurethral resection of prostate (TURP)
transurethral microwave thermotherapy (TUMT)
transurethral needle ablation of prostate (TUNA)
Others (laser, electropulvarization, etc.)
Medical:
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Watchful waiting
Drugs: alpha-blockers, finasteride
Rationale for Study
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Black elderly Medicare beneficiaries have lower rates
of many surgical procedures than Whites
TURP is performed 10% more frequently among
elderly Whites than among Blacks (Wasson JH , J Urol. 2000
164(4))
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New BPH surgeries do not require hospitalization and
are not known to have any different side effects or
complications than TURP
Little is known about the access (use) of new
procedures in general, by race, and these new BPH
procedures, in particular
Objective and Hypothesis
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Examine racial difference of new BPH
surgical procedures (TUMT and TUNA)
among elderly Medicare beneficiaries
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H0 - Blacks and Whites will receive new
BPH surgical procedures at equal rates
Data Source/Case Identification
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100% Medicare claims and Denominator files from
CMS
Identified any BPH procedures in Carrier, Inpatient, or
Outpatient claim file from 1999-2001
BPH procedure:
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CPT code: TURP (52601, 52612, 52614); TUMT (53850);
TUNA (53852)
ICD 9-CM procedure code: TURP (60.29); TUMT (60.96);
TUNA (60.97)
For procedures done in hospital or hospital outpatient, we matched physician and institution claims
to avoid duplication
Inclusion Criteria
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Black and white men only
Age ≥ 65
Enrolled in both Medicare Part A and
Part B during the study years
Not in managed care during the study
years
No End Stage Renal Disease
No history of prostate cancer
Study Cohort
% Total US Beneficiaries
Counties
Whites
Blacks
TUNA
631
409
57%
46%
69%
57%
TUMT/TUNA
783
64%
74%
558
378
690
55%
45%
63%
69%
57%
74%
Overall
TUMT
Restricted
TUMT
TUNA
TUMT/TUNA
Total sample size: 140,207 patients
Statistical Analysis
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Separate analysis for
 Total U.S.
 those counties where new procedures were
performed and had 10 or more black elderly male
beneficiaries
Race-specific procedure rates per 10,000 person
years
Direct standardization for age adjustment
Geographic heterogeneity was adjusted using
Generalized Estimate Equation model (GEE), Poisson
regression were used for adjusted rate ratios
Table 1: Age Adjusted BPH Procedure Rates among all
U.S. Medicare Beneficiaries, 1999-2001
Whites
Blacks
Procedures
Rate
Procedures
Rate
Rate
ratio
TURP
111,655
43.2
7,624
39.3
1.10
TUMT
15,479
6.0
547
2.8
2.14
TUNA
4,713
1.8
189
1.0
1.88
20,192
7.8
736
3.8
2.05
TUMT/TUNA
Rate: per 10,000 person years
Table 2: Age Adjusted Procedure Rates among Medicare
Beneficiaries in Procedure Counties, 1999-2001
Whites
Procedures
Blacks
Rate
Procedures
Rate
Rate
ratio
TURP
71337
42.9
5708
40.0
1.07
TUMT
10996
7.7
468
3.5
2.23
TUNA
3414
2.9
167
1.5
1.93
14860
9.2
643
4.4
2.07
TUMT/TUNA
Rate: per 10,000 person years
Note: Colored areas were restricted counties
* Purple color: Procedure performed only in Whites
Table 3: White/Black Rate Ratio Adjusted for Geographic
Variation among Medicare beneficiaries, 1999-2001
Unadjusted
Rate Ratio
Adjusted Rate Ratio
(95% CI)
p-value
TURP
1.07
1.10 (1.01,1.20)
0.0259
TUMT
2.23
1.67 (1.48,1.89)
<.0001
TUNA
1.93
1.51 (1.18,1.94)
0.0012
TUMT/TUNA
2.07
1.68 (1.48,1.91)
<.0001
Procedures
Data were restricted counties
CI: confidence interval
Conclusion
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White:Black rate ratio for TURP are consistent
with past reports and are an appropriate
surrogate for the need for new surgery
(RR=1.1)
Nationally, elderly Black Medicare beneficiaries
were significantly less likely to receive new BPH
surgical procedures than Whites (RR=2.1)
After adjusting for geographic variation,
differences between the races persist (RR=1.7)
Discussion
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Racial difference not due to availability
of procedure
Severity of BPH
Patient preference
Cost to patient – future study
Acknowledgement
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Research Data Assistance Center
(ResDAC), University of Minnesota
Coverage and Analysis Group, Centers for
Medicare and Medicaid Services (CMS)
Supported by CMS contract CMS 500-010043