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Minorites May Receive Less Timely MCI Diagnoses Than White Individuals

Researchers analyzed data from the 10,472 Medicare beneficiaries diagnosed with mild cognitive impairment or dementia in California.

Data from a recent study suggest that Asian, Black, and Hispanic patients receive less timely diagnoses of mild cognitive impairment (MCI) and dementia than White patients.1 

Researchers found that patients who identified as Asian (odds ratio [OR], 0.46 [95% CI, 0.38-0.56]; P <.001)), Black (OR, 0.73 [95% CI, 0.56-0.94]; P <.001), or Hispanic (OR, 0.62 [95% CI, 0.52-0.72]; P <.001)) were less likely to receive a timely diagnosis. Asian patients also received fewer diagnostic evaluation elements such as specialist evaluation, laboratory testing, and neuroimaging (incidence rate ratio [IRR], 0.81 [95% CI, 0.74-0.87]; P <.001)).

“Little is known about potential racial/ethnic differences with regard to timeliness and comprehensiveness of dementia diagnosis. Addressing this gap is of critical value for informing public health and policy interventions,” wrote first author Elena Tsoy, PhD, postdoctoral fellow, University of California, San Francisco, and colleagues.

Tsoy and colleagues analyzed data from 10,472 Medicare beneficiaries in California with incident diagnoses of dementia or MCI. Beneficiaries had a mean age of 82.9 years (standard deviation [SD], 8) and 6504 (62.1%) were women. Most patients identified as White (n = 7817; 74.6%), 1255 (12.0%) identified as Hispanic, 993 (9.5%) identified as Asian, and 407 (3.9%) identified as Black. A timely diagnosis was defined as diagnosis of MCI rather than dementia. 

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Altogether, only 21.2% of beneficiaries received a timely diagnosis of incident MCI (vs dementia), 34.6% received a specialist evaluation, 16.2% had recommended laboratory testing, and 28.7% had neuroimaging studies.

After adjusting for demographic and geographical factors, the aforementioned associations remained significant, with Asian beneficiaries having the lowest likelihood of an incident MCI diagnosis (OR, 0.45 [95% CI, 0.37-0.55]; P <.001), followed by Hispanic (OR, 0.65 [95% CI, 0.55-0.77]; P ≤.001) and Black (OR, 0.70 [95% CI, 0.53-0.91]; P = .01).

Further analyses revealed that the estimated mean marginal effects of race/ ethnicity on incident diagnosis of MCI were −11.0% (95% CI, −13.2% to −8.8%; P < .001) for Asian beneficiaries, −6.6% (95% CI, −8.9% to −4.2%; P < .001) for Hispanic beneficiaries, and −5.6% (95% CI, −9.4% to −1.7%; P = .01) for Black beneficiaries.

In a related editorial, Claudia Kawas, MD, Al and Trish Nichols Chair, clinical neuroscience and professor, neurology and neurobiology & behavior, University of California, Irvine, and colleagues wrote that “given the racial and ethnic diversification of the older population in the US and the higher burden of dementia in some ethnoracial groups, understanding the determinants of dementia as well as barriers to diagnosis in racially and ethnically diverse individuals is ever more crucial.”2

Tsoy and colleagues found that increasing age (OR for every additional 5 years, 0.80 [95% CI, 0.77-0.82]; P <.001), residence in a highly disadvantaged neighborhood (OR, 0.73 [95% CI, 0.63-0.84]; P <.001), and greater comorbidity burden (OR for every additional comorbid condition, 0.96 [95% CI, 0.94- 0.98]; P <.001) were also associated with a lower likelihood of an incident MCI diagnosis rather than dementia.

They also found that individuals who identified as Asian were less likely to receive recommended diagnostic workup services (IRR, 0.81 [95% CI, 0.74-0.87]; P <.001). This remained significant in fully adjusted models.

Marginal effects analyses showed a mean effect of −15.7% (95% CI, −21.2% to −10.2%; P <.001) of receiving recommended diagnostic services for Asian beneficiaries. Other variables associated with lower likelihood of diagnostic workup services were older age (IRR for every additional 5 years, 0.98 [95% CI, 0.98-0.99]; P <.001) and greater neighborhood disadvantage (IRR, 0.91 [95% CI, 0.86-0.96]; P = .003).

Tsoy and colleagues also found that Black beneficiaries residing in highly disadvantaged neighborhoods had a lower likelihood of receiving a diagnosis of MCI (B = 0.713; standard error [SE], 0.318; P = .02). A similar interaction was seen between Hispanic ethnicity and greater neighborhood disadvantage ((B = 0.133; SE, 0.050; P = .03) in association with the number of recommended diagnostic services.

Asian (OR, 0.40 [95% CI, 0.28- 0.55]; P <.001) and Hispanic (OR, 0.60 [95% CI, 0.46-0.78]; P <.001) beneficiaries that received a specialist evaluation were also less likely to receive a diagnosis of incident MCI than White beneficiaries.

“Recruiting diverse populations into research requires directed resources to cultivate trust and engage with different communities. Importantly, physicians must be made aware of the disproportionate effect of dementia in underrepresented and diverse communities and fully recognize the biases of the medical establishment in the diagnosis and care of these underserved individuals. It is a challenge we all must address,” Kawas and colleagues concluded.

REFERENCES
1. Tsoy E, Kiekhofer RE, Guterman EL, et al. Assessment of racial/ethnic disparities in timeliness and comprehensiveness of dementia diagnosis in California. JAMA Neurol. Published online March 29, 2021. doi:10.1001/jamaneurol.2021.0399
2. Kawas CH, Corrada MM, Whitmer RA. Diversity and disparities in dementia diagnosis and care: A challenge for all of us. JAMA Neurol. Published online March 29, 2021. doi:10.1001/jamaneurol.2021.0285