The Impact of Race on Intensity of Care Provided to Older Adults in the Medical Intensive Care Unit (original) (raw)
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Racial Variation in End-of-Life Intensive Care Use: A Race or Hospital Effect?
Health Services Research, 2006
Objective. To determine if racial and ethnic variations exist in intensive care (ICU) use during terminal hospitalizations, and, if variations do exist, to determine whether they can be explained by systematic differences in hospital utilization by race/ethnicity. Data Source. 1999 hospital discharge data from all nonfederal hospitals in Florida, Massachusetts, New Jersey, New York, and Virginia. Design. We identified all terminal admissions (N 5 192,705) among adults. We calculated crude rates of ICU use among non-Hispanic whites, blacks, Hispanics, and those with ''other'' race/ethnicity. We performed multivariable logistic regression on ICU use, with and without adjustment for clustering of patients within hospitals, to calculate adjusted differences in ICU use and by race/ethnicity. We explored both a randomeffects (RE) and fixed-effect (FE) specification to adjust for hospital-level clustering. Data Collection. The data were collected by each state. Principal Findings. ICU use during the terminal hospitalization was highest among nonwhites, varying from 64.4 percent among Hispanics to 57.5 percent among whites. Compared to white women, the risk-adjusted odds of ICU use was higher for white men and for nonwhites of both sexes (odds ratios [ORs] and 95 percent confidence intervals: white men 5 1.16 (1.14-1.19), black men 5 1.35 (1.17-1.56), Hispanic men 5 1.52 (1.27-1.82), black women 5 1.31 (1.25-1.37), Hispanic women 5 1.53 (1.43-1.63)). Additional adjustment for within-hospital clustering of patients using the RE model did not change the estimate for white men, but markedly attenuated observed differences for blacks (OR for men 5 1.12 (0.96-1.31), women 5 1.10 (1.03-1.17)) and Hispanics (OR for men 5 1.19 (1.00-1.42), women 5 1.18 (1.09-1.27)). Results from the FE model were similar to the RE model (OR for black men 5 1.10 (0.95-1.28), black women 5 1.07 (1.02-1.13) Hispanic men 5 1.17 (0.96-1.42), and Hispanic women 5 1.14 (1.06-1.24)) Conclusions. The majority of observed differences in terminal ICU use among blacks and Hispanics were attributable to their use of hospitals with higher ICU use rather than to racial differences in ICU use within the same hospital.
Journal of Palliative Medicine, 2016
Background: Racial differences exist for a number of health conditions, services, and outcomes, including endof-life (EOL) care. Objective: The aim of the study was to examine differences in processes of care in the last 7 days of life between African American and white inpatients. Methods: Secondary analysis was conducted of data collected in the Best Practices for End-of-Life Care for Our Nation's Veterans (BEACON) trial (conducted 2005-2011). Subjects were 4891 inpatient decedents in six Veterans Administration Medical Centers. Data were abstracted from decedents' medical records. Multi-variable analyses were conducted to examine the relationship between race and each of 18 EOL processes of care controlling for patient characteristics, study site, year of death, and whether the observation was pre-or post-intervention. Results: The sample consisted of 1690 African American patients (34.6%) and 3201 white patients (65.4%). African Americans were less likely to have: do not resuscitate (DNR) orders (odds ratio [OR]: 0.67; p = 0.004), advance directives (OR: 0.71; p = 0.023), active opioid orders (OR: 0.64, p = 0.0008), opioid medications administered (OR: 0.61, p = 0.004), benzodiazepine orders (OR: 0.68, p < 0.0001), benzodiazepines administered (OR: 0.61, p < 0.0001), antipsychotics administered (OR: 0.73, p = 0.004), and steroids administered (OR: 0.76, p = 0.020). Racial differences were not found for other processes of care, including palliative care consultation, pastoral care, antipsychotic and steroid orders, and location of death. Conclusions: Racial differences exist in some but not all aspects of EOL care. Further study is needed to understand the extent to which racial differences reflect different patient needs and preferences and whether interventions are needed to reduce disparities in patient/family education or access to quality EOL care.
The Influence of Race/Ethnicity and Socioeconomic Status on End-of-Life Care in the ICU
Chest, 2011
RATIONALE: There is conflicting evidence concerning the influence of race/ethnicity on utilization of intensive care at the end-of-life and little is known about the influence of socioeconomic status. METHODS: We examined patients dying in the ICU in 15 hospitals. Race/ethnicity was assessed as white and non-white. Socioeconomic status included patient education, health insurance, and income by zip code. To explore differences in end-of-life care, we examined use of 1) advance directives; 2) life-sustaining therapies; 3) symptom management; 4) communication; and 5) support services. RESULTS: Medical charts were abstracted for 3138/3400 patients of whom 2,479 (79%) were white and 659 (21%) were non-white (or Hispanic). In logistic regressions adjusted for patient demographics, socioeconomic factors and site, non-white patients were less likely to have living wills (OR 0.41, 95%CI=0.32-0.54), and more likely to die with full support (OR 1.59, 95%CI=1.30-1.94). In documentation of family conferences, nonwhite patients were more likely to have documentation that prognosis was discussed (OR 1.47, 95%CI=1.21-1.77) and that physicians recommended withdrawal of life support (OR 1.57, 95%CI=1.11-2.21). Non-whites were also more likely to have discord documented among family or with clinicians (OR 1.49, 95% CI=1.04-2.15).
The American Journal of Surgery, 2014
Background-Although various studies have documented increased Life-Sustaining Treatments (LST) among racial minorities in medical patients, whether similar disparities exist in surgical patients is unknown. Methods-Retrospective cohort study using the Nationwide Inpatient Sample (2006-2011) examining patients >39 years who died following elective colectomy. Primary predictor variable was race and main outcome was use of LST. Results-In univariate analysis, significant differences existed in use of CPR (Black-35.9%, Hispanic-29.0%, Other-24.5%, White-11.7%, p = 0.002) and re-intubation (Hispanic-75.0%, Other-69.0%, Black-52.3%, White-45.2%, p = 0.01). In multivariate analysis, Black (OR3.67, p=0.01) and Hispanic (4.21, p=0.03) patients were more likely to have undergone CPR, and Hispanic patients (4.24, p=0.01) were more likely to have been re-intubated (reference: White). Conclusions-Blacks and Hispanics had increased odds of experiencing CPR, and Hispanics were more likely to have been re-intubated before death following a major elective operation. These variations may imply worse quality of death and increased associated costs.