Nursing home residence confounds gender differences in Medicare utilization an example of Simpson's paradox

UMMS Affiliation

Department of Quantitative Health Sciences

Publication Date


Document Type



Aged; Aged, 80 and over; Confounding Factors (Epidemiology); Eligibility Determination; Female; Health Expenditures; Humans; Male; Medicare; Models, Statistical; Nursing Homes; Quality of Health Care; Reimbursement Mechanisms; Retrospective Studies; Sex Distribution; Terminal Care; Terminally Ill; United States


Biostatistics | Epidemiology | Health Services Research


BACKGROUND: Gender differences in health care utilization in older Americans may be confounded by nursing home residence. Medicare data contain several files that can be used to create a measure of nursing home residence, but prior work has not addressed which best account for potential confounding. Simpson's paradox occurs when aggregated data support a different conclusion from what the disaggregated data show. We describe such a paradox that appeared when we sharpened our definition of "nursing home residence" while examining gender differences in Medicare utilization at the end of life.

METHODS: To understand gender-specific health care utilization at the end of life, we conducted a retrospective analysis of a national random sample of Medicare beneficiaries aged 66 or older who died in 2001 with Parts A and B data for 18 months before death. We sought to associate each of total hospital days and costs during the final 6 months of life with numbers of primary care physician visits in the 12 preceding months. In addition to demographics, comorbidities, and geography, "nursing home residence" was a potential confounder, which we imputed in two ways: 1) from skilled nursing facility bills in the Part A Medicare Provider Analysis and Review (MedPAR) file; and 2) from Berenson-Eggers-Type-of-Service codes indicating widely spaced doctor visits in nursing homes obtained from Medicare's carrier file.

CONCLUSION: Gender differences in Medicare utilization are strongly confounded by nursing home resident status, which can be imputed well from Medicare's carrier file, but not MedPAR. Inc. All rights reserved.

DOI of Published Version



Womens Health Issues. 2010 Mar-Apr;20(2):105-13. Epub 2010 Feb 10. Link to article on publisher's site

Journal/Book/Conference Title

Women's health issues : official publication of the Jacobs Institute of Women's Health

PubMed ID


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Link to Article in PubMed