The effect of medical school, residency program, and health system board characteristics on AD/ADRD care quality and outcomes. - Project Summary High-quality care throughout the trajectory of illness of Alzheimer's disease and Alzheimer's disease- related dementias (AD/ADRD) has been shown to be associated with a better quality of life, lower caregiver distress, and reduced use of acute and long-term care. However, racial and ethnic (R&E) minoritized persons with AD/ADRD often receive poorer quality care than White patients, including lower rates of advance directives, reduced receipt of anti-dementia medications, and increased end-of-life hospitalizations. Although governmental and institutional policies influence R&E diversity in medical education/training and work environments, little is known about how R&E diversity in medical education, residency training, and health system leadership affect R&E disparities in AD/ADRD care. This knowledge gap has hindered efforts to develop interventions that could effectively eliminate disparities in AD/ADRD care. The proposed study will address these important knowledge gaps by applying the quasi-experimental methods to the comprehensive data on patients, physicians, medical schools, residency programs, and health systems we will develop by linking 7 nationally-representative databases (Medicare Claims Data, Consumer Assessment of Healthcare Providers and Systems Data, Doximity Physician Data, Association of American Medical Colleges Medical School Data, American Medical Association Residency Program Data, RAND Health System Data, and American Hospital Association National Health Care Governance Survey Data). In Aim 1, we will determine the effect of the R&E diversity of medical school student bodies from which physicians graduated on disparities in AD/ADRD care, by applying the quasi-experimental instrumental variable method using the state affirmative action bans as an instrument. The state affirmative action bans serve as an ideal instrument because they are strongly associated with medical school student body diversity, but do not directly affect AD/ADRD care. In Aim 2, we will determine the effect of 4 residency program characteristics (higher R&E diversity of residents, presence of cultural competence awareness program, instruction in medical Spanish or other non-English languages, and rotation at the county and safety-net hospitals) on R&E disparity in AD/ADRD care, using the propensity score matching method. In Aim 3, we will determine the effect of R&E diversity of health system boards on disparities in AD/ADRD care, by applying the propensity score matching method. This project will provide a robust evidence base for policymakers to develop policy interventions (e.g., increasing R&E diversity and introducing the cultural competency awareness program at medical schools, residency programs, and health systems) that could effectively mitigate R&E disparities in AD/ADRD care. The research team consists of investigators with expertise in all relevant fields (Alzheimer's disease and dementia research, R&E disparity research, medical education and training, organizational behaviors, physician and health system performance, and econometric and statistical methods) to conduct this innovative research.
