ABSTRACT Motivated by soaring spending and stagnating life expectancy, the first 20 years of this Program Project Grant (PPG) has focused on the causes and consequences of healthcare efficiency in the U.S. This work has advanced fundamental scientific knowledge regarding sources of inefficiency and has motivated significant changes in healthcare policy and delivery for millions of Americans. This competitive renewal responds to the NIA’s prioritization of Alzheimer’s disease and related dementia (ADRD)-related research and to eliminating health disparities by shifting the focus of this PPG to inequities in healthcare services and delivery for persons with ADRD and with a lens on racial inequities. This is a new framework from the work to-date produced by this PPG. Inequity is a particularly egregious form of healthcare inefficiency. Recent PPG research showed excess mortality among older adults with ADRD, especially for Asian, Black, and Hispanic populations and people living in nursing homes, even in areas with low COVID-19 prevalence. Intersectional inequities in ADRD care delivery run the gamut from differential exposure to the modifiable risks that contribute to development of ADRD, initial diagnosis and referral, ongoing treatment and support, and throughout later stages, including end-of-life care. Conceptually, the determinants of individual health outcomes will be documented among persons with ADRD from the social ecological perspective which recognizes nested ‘systems’ that interact with one another (individual, interpersonal, organizational, structural, community, and policy) and their attendant social determinants of health. This PPG renewal, therefore, proposes projects focusing on each concentric circle of this model and their interactions. Project 1 will explore state-level policy heterogeneity and its influence on access to home and community-based services for nursing home eligible adults with ADRD. Project 2 will test the hypothesis that having resident service coordinators for adults who live in affordable senior housing decreases adverse health care service use and increases home and community-based service use for low- income residents with ADRD. Project 3 will explore trends in the quality of primary care for people with ADRD and to identify modifiable policy-, system- and practice-level factors that contribute to better outcomes. Finally, Project 4 will develop a novel measure of bias in provider diagnostic test ordering in the acute care setting and explore the impact of diagnosis on the trajectory of patients with ADRD. Projects achieve synergy by using the social ecological model to examine how interactions among the key variables examined in each project could operate together to improve outcomes and reduce inequities, and by relying on shared administrative, data and analysis, and methodology cores.

NARRATIVE Motivated by soaring spending and stagnating life expectancy, the first 20 years of this PPG have focused on the causes and consequences of health care efficiency in the U.S. In this competitive renewal application, we respond to the NIA’s call to focus our research exclusively on persons with ADRD. While there are many forms of inefficiency in ADRD diagnosis, treatment, and care, we are interested primarily in inequity in care delivery as a form of inefficiency. We seek to advance knowledge regarding how the structural influences of state and federal policies, the organization and structure of health care services, and implicit and explicit biases in clinical decision-making influence medical and social care received by persons with ADRD, especially those from racialized and marginalized groups.