Early Performance of Hospital Value-based Purchasing Program in Medicare: A Systematic Review.

BACKGROUND: Under the Affordable Care Act, the Centers for Medicare and Medicaid Services has greatly expanded inpatient fee-for-value programs including the Hospital Value-based Purchasing (HVBP) program. Existing evidence from the HVBP program is mixed. There is a need for a systematic review of the HVBP program to inform discussions on how to improve the program's effectiveness. OBJECTIVE: To review and summarize studies that evaluated the HVBP program's impact on clinical processes, patient satisfaction, costs and outcomes, or assessed hospital characteristics associated with performance on the program. DESIGN: We searched the MEDLINE/PubMed, Scopus, ProQuest database for literature published between January 2013 and July 2019 using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. RESULTS: Of 988 studies reviewed, 33 studies that met the selection criteria were included. A small group of studies (n=7) evaluated the impact of the HVBP program, and no impact on processes or patient outcomes was reported. None of the included studies evaluated the effect of HVBP program on health care costs. Other studies (n=28) evaluated the hospital characteristics associated with HVBP performance, suggesting that safety-net hospitals reportedly performed worse on several quality and cost measures. Other hospital characteristics' associations with performance were unclear. CONCLUSIONS: Our findings suggest that the current HVBP does not lead to meaningful improvements in quality of care or patient outcomes and may negatively affect safety-net hospitals. More rigorous and comprehensive adjustment is needed for more valid hospital comparisons.

Reported experiences with Medicaid managed care models among parents of children.

The proportion of children enrolled in Medicaid managed care arrangements has grown significantly over the past decade. Yet, few studies have attempted to assess differences in parental reports and ratings of care for children enrolled in different types of Medicaid managed care. We examine parental reports and ratings of care to explore whether and how patient and parent experiences vary by child health status and managed care plan type, including provider-sponsored specialized plans serving only children. Parents of children in a Florida Medicaid demonstration project in two counties over 3 years were surveyed using Consumer Assessment of Health Providers and Systems surveys (n = 2,741-11,067). Ordered logistic regression models with interaction terms were used to assess relationships between plan type, presence of chronic condition, and measures of patient experience. Parents of children enrolled in provider-sponsored plans that focus on pediatrics were more likely to provide a positive rating for their doctor, health plan, and specialty care compared to parents of children in an health maintenance organization (HMO). Parents of children with a chronic condition were less likely than parents of children without a chronic condition to provide a favorable rating of overall health care, their doctor, or health plan. The interaction term that assessed whether patient experience by plan type was impacted by the child's health status was not statistically significant. Parents of Medicaid children may prefer provider-sponsored arrangements over HMOs. Findings can inform the future development of other integrated models of care involving provider-sponsored arrangements, such as pediatric Accountable Care Organizations and Patient-Centered Medical Homes.

Determinants of hospital fall rate trajectory groups: a longitudinal assessment of nurse staffing and organizational characteristics.

BACKGROUND: Patient falls in acute care hospitals represent a significant patient safety concern. Although cross-sectional studies have shown that fall rates vary widely between acute care hospitals, it is not clear whether hospital fall rates remain consistent over time. PURPOSE: The aim of this study was to determine whether hospitals can be categorized into fall rate trajectory groups over time and to identify nurse staffing and hospital characteristics associated with hospital fall rate trajectory groups. METHODOLOGY/APPROACH: We conducted a 54-month (July 2006-December 2010) longitudinal study of U.S. acute care general hospitals participating in the National Database for Nursing Quality Indicators (2007). We used latent class growth modeling to categorize hospitals into groups based on their long-term fall rates. Nurse staffing and hospital characteristics associated with membership in the highest hospital fall rate group were identified using logistic regression. FINDINGS: A sample of 1,529 hospitals (mean fall rate of 3.65 per 1,000 patient days) contributed data to the analysis. Latent class growth modeling findings classified hospital into three groups based on fall rate trajectories: consistently high (mean fall rate of 4.96 per 1,000 patient days), consistently medium (mean fall rate of 3.63 per 1,000 patient days), and consistently low (mean fall rate of 2.50 per 1,000 patient days). Hospitals with higher total nurse staffing (odds ratio [OR] = 0.92, 95% confidence interval [CI] [0.85, 0.99]), Magnet status (OR = 0.49, 95% CI [0.35, 0.70]), and bed size greater than 300 beds (OR = 0.70, 95% CI [0.51, 0.94]) were significantly less likely to be categorized in the "consistently high" fall rate group. PRACTICE IMPLICATIONS: Over this 54-month period, hospitals were categorized into three groups based on long-term fall rates. Hospital-level factors differed among these three groups. This suggests that there may be hospitals in which "best practices" for fall prevention might be identified. In addition, administrators may be able to reduce fall rates by maintaining greater nurse staffing ratios as well as fostering an environment consistent with that of Magnet hospitals.

Preparedness of rural physicians for bioterrorist events in Florida.

OBJECTIVES: Human-induced public health emergencies such as the anthrax bioterrorism event and the terrorism events of September 11, 2001 in the United States have increased awareness of the nation's vulnerability to large-scale emergencies. Scant attention has been given to preparing physicians in sparsely populated areas for public health emergencies. This study introduces a conceptual model developed from participants' responses that can be used to improve our understanding of rural physicians' preparedness regarding public health emergencies such as a bioterrorism event. The conceptual model is valuable because it illustrates some areas of question, concern, and future inquiry regarding bioterrorism preparedness. METHODS: This study used a qualitative research approach and grounded theory methods for data analysis. Semistructured interviews were conducted among six rural physicians in Florida. Florida was considered a particularly appropriate location given that the state was an initial site of the 2001 anthrax attacks. In addition, approximately half of Florida's counties are considered rural. RESULTS: The findings of this study suggest that not all rural physicians in Florida believe that they are adequately prepared for a bioterrorism event. The conceptual model elements--cognitive, clinical, expectation, and simulation--emerged from an analysis of participant responses. CONCLUSIONS: According to participant responses and the formulation of the conceptual model it may be postulated that preparedness may be effectively achieved if physicians are aware of the possibility of bioterrorism through education and seminars, able to suspect and recognize an event when it occurs, and institute appropriate medical management.

The health care utilization model: Application to dental care use for Black and Hispanic children.

OBJECTIVES: To explore the pathway associated with dental service use among Hispanic and non-Hispanic Black children, applying Andersen's model of health care service utilization. METHODS: Samples of Hispanic (n = 5,055) and non-Hispanic (NH) Black (n = 2,695) children aged 2-17 years from the 2016 National Survey of Children's Health (NSCH) were included in this study. We used structural equation modeling (SEM) to examine the path of the relationship between dental care visits and the three groups of characteristics in Andersen's behavioral model. RESULTS: In the models for Hispanic and non-Hispanic Black children, parents' educational attainment directly and positively affected income and having insurance. Also, insurance (Hispanic children: ß = 0.17, P ≤ 0.01; NH Black children: ß = 0.25, P ≤ 0.01) and age of the child (Hispanic children: ß = 0.14, P ≤ 0.01; NH Black: ß = 0.21, P ≤ 0.01) directly and positively affected dental care use. However, there was no direct effect of the need factor on dental care use in either model. CONCLUSIONS: Children may receive dental services that eliminate acute dental problems, probably as a result of the ACA and CHIP coverage. The patterns of findings suggest the need for policy changes to improve pediatric dental coverage and promote professional recommendations for effective dental hygiene.

Outsourcing administrative functions: service organization demonstrations and Florida Medicaid PCCM program costs.

This study examines the cost implications of outsourcing Medicaid functions to the private sector. We examine the expenditures for enrollees in three Medicaid primary care case management (PCCM) demonstration projects compared to Florida's PCCM program from February 2002-February 2003. The RAND two-part model was used to analyze the medica expenditures for enrollees in each program. After adjusting for sociodemographic factors and the probability of service use, we found that all three demonstration projects reduced expenditures compared to the PCCM program. The implications from the study are that Medicaid programs may want to consider outsourcing PCCM functions after further studies examine the utilization experience for enrollees in these programs.

The pivotal impact of center characteristics on survival of candidates listed for deceased donor kidney transplantation.

BACKGROUND: There are currently over half a million end-stage renal disease patients and >70,000 patients listed to receive a deceased donor kidney transplant in the United States. To receive a deceased donor transplant, patients are placed on a waiting list at one of approximately 240 centers. Although candidate decisions to list at a particular center may often be made passively (based on proximity or physician referral), the important question remains as to whether the center of listing has a significant impact on patient outcomes. METHODS: The study evaluated adult kidney transplant candidates in the United States listed from 1995 to 2000 (n = 108,928) with follow-up through 2006. The primary outcome of patient survival was investigated with survival models evaluated with respect to 4 center characteristics (volume, donor quality, waiting time, past performance). Center characteristics derived from years preceding listing, simulating information that could be attainable for prospective candidates. RESULTS: Center waiting time had a marked association with survival (Adjusted hazard ratio = 1.32, 95% confidence interval: 1.27-1.38 for the longest waiting times). Past performance and donor quality also had significant association with survival; center volume was not a significant factor. The cumulative impact of center factors resulted in an average 4-year difference in life expectancy. Center characteristics at listing were strongly correlated with levels at the time of transplantation and centers with the "best" characteristics were located in every region of the country. CONCLUSIONS: Center characteristics have significant impact on kidney transplant candidate survival. Information regarding the variability and importance of center factors should be clearly disseminated to transplant candidates.

Patient-level and practice-level characteristics associated with receipt of preventive dental services: 48-month incidence.

OBJECTIVES: This study aims to: (a) quantify the incidence of preventive dental services [in-office fluoride application and dental cleaning (prophylaxis)]; (b) determine if these services are effectively targeted to patients with the highest need; and (c) quantify the role of practice characteristics and patient-level factors in service receipt. METHODS: A population-based prospective cohort study was conducted with 873 adults who had at least one tooth at baseline, 743 of whom provided 48-month data. In-person interviews and clinical examinations were conducted biennially for 48 months, with 6-monthly telephone interviews in between. Dental records were abstracted afterward, and practices that served participants completed questionnaires. Analysis was limited to persons with at least one dental visit of any type during follow-up (87 percent of the sample). RESULTS: Only 9 percent of the persons received at least one fluoride application; 75 percent received a dental cleaning. Persons with high need were actually less likely to have received preventive services. In multivariable regression analyses, characteristics of the practice in which the subject received care were very strongly related to fluoride receipt, independent of patient-specific characteristics. CONCLUSIONS: One preventive procedure was common; the other was uncommon. However, practices did not effectively target high-risk patients for either procedure. Instead, both services were typically received by persons with the least need for them. These findings are consistent with the conclusion that practitioners greatly influenced the delivery of fluoride services, with substantial contributions also made by patient-level predisposing and enabling factors for both preventive services.

Benchmarking Implications: Analysis of Medicare Accountable Care Organizations Spending Level and Quality of Care.

Early evidence has shown that Accountable Care Organizations (ACOs) have achieved some success in improving the quality of care and reducing Medicare costs. However, it has been argued that the ACO rewarding model may disproportionately affect relatively low-spending (LS; considered as efficient) organizations that have fewer options to cut unnecessary services compared with high-spending (HS; inefficient) organizations. We conducted a cross-sectional retrospective study to compare ACO financial and quality of care performance between HS-ACO and LS-ACO. After adjusting for ACO organizational factors and beneficiary characteristics, we found that HS-ACOs generated greater savings per beneficiary than LS-ACOs ($501 vs. -$108, p < .001); however, HS-ACOs had a lower quality of care performance (48.79 vs. 53.29, p = .002). Specifically, LS-ACOs had better quality performance than HS-ACOs in patient experience/satisfaction (p = .02), preventive care services (p = .004), and hospitalization management (p = .001), whereas HS-ACOs better performed in routine checkup/follow-up (p < .001) and risk population management (p = .048). Our findings indicated that Medicare ACO rewarding model seems to be advantageous for HS-ACOs regardless of the overall quality of care performance.

Deceased donor kidney and liver transplantation to nonresident aliens in the United States.

BACKGROUND: Policies governing the allocation of deceased donor organs to nonresident aliens (NRAs) have existed from the early days of transplantation. However, there is a paucity of research describing this population. The aim of the present study is to examine characteristics and allocation patterns for NRAs compared to U.S. citizens in the context of the two most common forms of solid organ transplantation. METHODS: The study included kidney and liver transplant candidates and deceased donor transplant recipients from 1988-2005 in the United States. We describe demographic characteristics, insurance coverage, geographic variability, and donor relationship based on citizenship and residency status. We additionally examined the association of citizenship with time to transplantation utilizing survival models. RESULTS: From 1988-2005, there were 2724 solitary kidney and 2072 liver NRA candidate listings with United Network for Organ Sharing. NRA recipients had more self-pay (liver 36% and kidney 22%) and foreign sources (liver 26% and kidney 13%) of insurance coverage. Transplants to NRAs were more frequent than deceased donations deriving from NRAs for both organs. Adjusted models indicated that NRA kidney candidates received transplants at the same rate as U.S. citizens while liver NRA candidates received transplants more rapidly during the pre-Model for End-Stage Liver Disease (MELD; adjusted hazard ratio [AHR] 1.2, confidence interval [CI] 1.2-1.3) and post-MELD (AHR 1.5, CI 1.3-1.7) eras. CONCLUSIONS: NRAs are demographically and socioeconomically diverse and have historically had a more rapid progression on the waiting list to receive a liver transplant. Further discussion and investigation concerning the ethical, economic, and public health ramifications of transplantation to NRA patients are warranted.

Satisfaction with dental appearance among diverse groups of dentate adults.

OBJECTIVES: To quantify (a) the prevalence of dissatisfaction with dental appearance in a diverse sample of dentate adults and (b) the associations between dissatisfaction with dental appearance, sociodemographic factors, and other measures of oral health. METHODS: Data were taken from the Florida Dental Care Study , a population-based longitudinal cohort study of oral health and related behaviors. The sample included 873 participants at baseline. Descriptive analysis and logistic regression were conducted to analyze the baseline data in the current report. RESULTS: Females, problem-oriented dental attenders, and participants who had not completed high school were significantly more dissatisfied with their dental appearance than their respective counterparts. Dissatisfaction with dental appearance was also independently associated with six specific clinical and self-reported measures of oral health. DISCUSSION: Dissatisfaction with dental appearance was common in this population-based sample of middle-aged and older adults, and was significantly associated with key sociodemographic and oral health factors.

Florida nurse practitioners' attitudes and practices regarding oral cancer prevention and early detection.

PURPOSE: To examine Florida nurse practitioners' (NPs') attitudes and practices regarding oral cancer prevention and early detection. DATA SOURCE: A statewide mail survey was conducted among Florida NPs who provided primary care. The questionnaire was adapted from an existing survey instrument used to measure NPs' knowledge, attitudes, and practices about oral cancer prevention and early detection. A total of 448 Florida NPs (33% response rate) completed the survey. CONCLUSIONS: Florida NPs reportedly were not well prepared for oral cancer prevention and early detection. Although most NPs realized the importance of annual oral cancer screening for high-risk populations and held positive attitudes toward the benefit of early detection, only 39.3% of respondents thought his or her knowledge about oral cancer was current and more than half had never provided oral cancer examinations. IMPLICATIONS FOR PRACTICE: Florida has among the nation's highest oral cancer rates, but persons at highest risk are among those least likely to see a dentist. Therefore, a multidisciplinary approach involving all relevant healthcare providers, including NPs, may be more effective than relying only on dentists' efforts in improving survival rates for oral cancer. Strategies are needed to increase the involvement of Florida's NPs in oral cancer detection.

Comparative effectiveness of dual vs. single-action antidepressants on HIV clinical outcomes in HIV-infected people with depression.

OBJECTIVE: Depression is highly prevalent among people living with HIV/AIDS (PLWHA) and has deleterious effects on HIV clinical outcomes. We examined changes in depression symptoms, viral suppression, and CD4 T cells/µl among PLWHA diagnosed with depression who initiated antidepressant treatment during routine care, and compared the effectiveness of dual-action and single-action antidepressants for improving those outcomes. DESIGN: Comparative effectiveness study of new user dual-action or single-action antidepressant treatment episodes occurring from 2004 to 2014 obtained from the Center for AIDS Research Network of Integrated Clinical Systems. METHODS: We identified new user treatment episodes with no antidepressant use in the preceding 90 days. We completed intent-to-treat and per protocol evaluations for the main analysis. Primary outcomes, were viral suppression (HIV viral load <200 copies/ml) and CD4 T cells/µl. In a secondary analysis, we used the Patient Health Questionnaire-9 (PHQ-9) to evaluate changes in depression symptoms and remission (PHQ <5). Generalized estimating equations with inverse probability of treatment weights were fitted to estimate treatment effects. RESULTS: In weighted intent-to-treat analyses, the probability of viral suppression increased 16% after initiating antidepressants [95% confidence interval = (1.12, 1.20)]. We observed an increase of 39 CD4T cells/µl after initiating antidepressants (30, 48). Both the frequency of remission from depression and PHQ-9 scores improved after antidepressant initiation. Comparative effectiveness estimates were null in all models. CONCLUSION: Initiating antidepressant treatment was associated with improvements in depression, viral suppression, and CD4 T cells/µl, highlighting the health benefits of treating depression in PLWHA. Dual and single-action antidepressants had comparable effectiveness.

Comparative effectiveness of dual-action versus single-action antidepressants for the treatment of depression in people living with HIV/AIDS.

BACKGROUND: Depression is the most common psychiatric comorbidity among people living with HIV/AIDS (PLWHA). Little is known about the comparative effectiveness between different types of antidepressants used to treat depression in this population. We compared the effectiveness of dual-action and single-action antidepressants in PLWHA for achieving remission from depression. METHODS: We used data from the Centers for AIDS Research Network of Integrated Clinic Systems to identify 1175 new user dual-action or single-action antidepressant treatment episodes occurring from 2005 to 2014 for PLWHA diagnosed with depression. The primary outcome was remission from depression defined as a Patient Health Questionnaire-9 (PHQ-9) score <5. Mean difference in PHQ-9 depressive symptom severity was a secondary outcome. The main approach was an intent-to-treat (ITT) evaluation complemented with a per protocol (PP) sensitivity analysis. Generalized linear models were fitted to estimate treatment effects. RESULTS: In ITT analysis, 32% of the episodes ended in remission for both dual-action and single-action antidepressants. The odds ratio (OR) of remission was 1.02 (95%CI=0.63,1.67). In PP analysis, 40% of dual-action episodes ended in remission compared to 32% in single-action episodes. Dual-action episodes had 1.33 times the odds of remission (95%CI=0.55,3.21), however the result was not statistically significant. Non-significant differences were also observed for depressive symptom severity. LIMITATIONS: Missing data was common but was addressed with inverse probability weights. CONCLUSIONS: Results suggest that single-action and dual-action antidepressants are equally effective in PLWHA. Remission was uncommon highlighting the need to identify health service delivery strategies that aid HIV providers in achieving full remission of their patients' depression.

Variations in health insurance coverage for rural and urban nonelderly adult residents of Florida, Indiana, and Kansas.

CONTEXT: Evidence exists for differences in health insurance coverage among states, but less is known about variations across different kinds of communities within states. PURPOSE: This article assesses the role of residential setting (metropolitan county, rural adjacent, and rural nonadjacent) in health insurance coverage for adult residents, under age 65, using data from large-scale surveys collected in 3 diverse states (Florida, Indiana, and Kansas). METHODS: Descriptive statistics are provided, and logistic regression models are used to examine the relationship between uninsurance status and residential settings while controlling for personal characteristics. Adjusted uninsurance rates by residential settings are presented for each state. FINDINGS: Residential settings are significantly associated with uninsurance status in 2 of the 3 states we examined. We find that adult Floridians of rural adjacent counties are more likely to be uninsured than those in urban counties, but, for Indiana residents, uninsurance status is comparable between urban and rural adjacent residents. Rural nonadjacent Indiana residents are more likely to be uninsured compared to those in urban counties. The insurance status of adult Kansans does not vary across residential settings. CONCLUSION: Residential settings are significantly associated with being uninsured, but the significance of this link between residential locations and uninsurance status varies from state to state.

Sustainability of school-located influenza vaccination programs in Florida.

BACKGROUND: School-located influenza vaccination (SLIV) programs are a promising strategy for increasing vaccination coverage among schoolchildren. However, questions of economic sustainability have dampened enthusiasm for this approach in the United States. We evaluated SLIV sustainability of a health department led, county-wide SLIV program in Alachua County, Florida. Based on Alachua's outcome data, we modeled the sustainability of SLIV programs statewide using two different implementation costs and at different vaccination rates, reimbursement amount, and Vaccines for Children (VFC) coverage. METHODS: Mass vaccination clinics were conducted at 69 Alachua County schools in 2013 using VFC (for Medicaid and uninsured children) and non-VFC vaccines. Claims were processed after each clinic and submitted to insurance providers for reimbursement ($5 Medicaid and $47.04 from private insurers). We collected programmatic expenditures and volunteer hours to calculate fixed and variable costs for two different implementation costs (with or without in-kind costs included). We project program sustainability for Florida using publicly available county-specific student populations and health insurance enrollment data. RESULTS: Approximately 42% (n=12,853) of pre-kindergarten - 12th grade students participated in the SLIV program in Alachua. Of the 13,815 doses provided, 58% (8042) were non-VFC vaccine. Total implementation cost was $14.95/dose or $7.93/dose if "in-kind" costs were not included. The program generated a net surplus of $24,221, despite losing $4.68 on every VFC dose provided to Medicaid and uninsured children. With volunteers, 99% of Florida counties would be sustainable at a 50% vaccination rate and average reimbursement amount of $3.25 VFC and $37 non-VFC. Without volunteers, 69% of counties would be sustainable at 50% vaccination rate if all VFC recipients were on Medicaid and its reimbursement increased from $5 to $10 (amount private practices receive). CONCLUSIONS AND RELEVANCE: Key factors that contributed to the sustainability and success of an SLIV program are: targeting privately insured children and reducing administration cost through volunteers. Counties with a high proportion of VFC eligible children may not be sustainable without subsidies at $5 Medicaid reimbursement.

The identification of high-cost patients.

The authors examine whether retrospective claims data are useful to distinguish future high-cost cases among the uninsured. They rely on internal claims and accounting data for the calendar years from 1999 to 2001 from a representative safety net facility to describe the distribution of costs and any characteristics that distinguish high-cost patients from other uninsured patients. They conclude that administrative data combined with in-depth survey information could be a useful approach for identifying cases for intensive case management.

Incidence of tooth loss and prosthodontic dental care: effect on chewing difficulty onset, a component of oral health-related quality of life.

OBJECTIVES: To quantify incidence of tooth loss, prosthodontic dental restoration, and chewing difficulty onset and the effect of tooth loss and prosthodontic restoration on chewing difficulty onset. DESIGN: A prospective cohort study of oral health and related behaviors with in-person interviews and clinical examinations conducted at baseline and 24 months. Telephone interviews were conducted every 6 months between these sessions. SETTING: A community-based sample of four counties in north Florida. PARTICIPANTS: Eight hundred seventy-three persons who had at least one tooth and were aged 45 and older at baseline. MEASUREMENTS: Persons were queried regarding onset of chewing difficulty, an important component of oral health-related quality of life (OHRQoL). The chewing index of Leake, with minor revision, was the primary outcome of interest. Tooth loss was measured using direct clinical examination. Dental care use was reported during each interview. RESULTS: Approximately 22% of participants reported tooth loss during follow-up. Fixed prosthodontics (crowns and bridges) was the most common form of new prosthodontic treatment. People who reported tooth loss were 2.7 times more likely to report chewing difficulty onset than people without tooth loss (P<.001). Having fewer occluding pairs of teeth at baseline was significantly associated with an increased probability of chewing difficulty onset. People who received removable prosthodontic treatment were much less likely to report chewing difficulty onset than people who did not (P<.01). CONCLUSION: Incident tooth loss and removable prosthodontic restoration strongly predicted chewing difficulty, an important component of OHRQoL.

Social determinants of tooth loss.

OBJECTIVES: To quantify racial and socioeconomic status (SES) disparities in oral health, as measured by tooth loss, and to determine the role of dental care use and other factors in explaining disparities. DATA SOURCES/STUDY SETTING: The Florida Dental Care Study, comprising African Americans (AAs) and non-Hispanic whites 45 years old or older who had at least one tooth. STUDY DESIGN: We used a prospective cohort design. Relevant population characteristics were grouped by predisposing, enabling, and need variables. The key outcome was tooth loss, a leading measure of a population's oral health, looked at before and after entering the dental care system. Tooth-specific data were used to increase inferential power by relating the loss of individual teeth to the disease level on those teeth. DATA COLLECTION METHODS: In-person interviews and clinical examinations were done at baseline, 24, and 48 months, with telephone interviews every 6 months. PRINCIPAL FINDINGS: African Americans and persons of lower SES reported more new dental symptoms, but were less likely to obtain dental care. When they did receive care, they were more likely to experience tooth loss and less likely to report that dentists had discussed alternative treatments with them. At the first stage of analysis, differences in disease severity and new symptoms explained tooth loss disparities. Racial and SES differences in attitudes toward tooth loss and dental care were not contributory. Because almost all tooth loss occurs by means of dental extraction, the total effects of race and SES on tooth loss were artificially minimized unless disparities in dental care use were taken into account. CONCLUSIONS: Race and SES are strong determinants of tooth loss. African Americans and lower SES persons had fewer teeth at baseline and still lost more teeth after baseline. Tooth-specific case-mix adjustment appears, statistically, to explain social disparity variation in tooth loss. However, when social disparities in dental care use are taken into account, social disparities in tooth loss that are not directly due to clinical circumstance become evident. This is because AAs and lower SES persons are more likely to receive a dental extraction once they enter the dental care system, given the same disease extent and severity. This phenomenon underscores the importance of understanding how disparities in health care use, dental insurance coverage, and service receipt contribute to disparities in health. Absent such understanding, the total effects of race and SES on health can be underestimated.