Dataset Information

The Paradox of End-of-Life Hospital Treatment Intensity among Black Patients: A Retrospective Cohort Study.

ABSTRACT:

Objective

Black patients are more likely than white patients to die in the hospital with intensive care and life-sustaining treatments and less likely to use hospice. Regional concentration of high end-of-life (EOL) treatment intensity practice patterns may disproportionately affect black patients. We calculated and compared race-specific hospital-level EOL treatment intensity in Pennsylvania.

Methods

We conducted a retrospective cohort analysis of Pennsylvania acute care hospital admissions, 2001-2007, among black and white admissions ≥21 years old at high probability of dying (HPD) (≥15% predicted probability of dying at admission). We calculated hospitals' race-specific observed, expected, and Bayes' shrunken observed-to-expected ratios of intensive care unit (ICU) admission, ICU length of stay (LOS), intubation/mechanical ventilation, hemodialysis, tracheostomy, and gastrostomy among HPD admissions; and an empirically weighted EOL treatment intensity index summing these ratios.

Results

There were 35,609 black HPD admissions (27,576 unique patients) and 311,896 white HPD admissions (252,662 unique patients) to 182 hospitals. Among 95 hospitals with ≥30 black HPD admissions, 80% of black admissions were concentrated in 29 hospitals, where black-specific observed and expected EOL measures were usually higher than white-specific measures (p < 0.001 for all but 5/24 measures). Hospitals' black-specific and white-specific observed-to-expected ratios of ICU and life-sustaining treatment (LST) (rho 0.52-0.90) and EOL index (rho = 0.92) were highly correlated. However, black-specific observed-to-expected ratios and overall EOL intensity index were consistently lower than white-specific ratios (p < 0.001 for all except hemodialysis).

Conclusions

In Pennsylvania, black-serving hospitals have higher standardized EOL treatment intensity than nonblack-serving hospitals, contributing to black patients' relatively higher use of intensive treatment. However, conditional on being admitted to the same high-intensity hospital and after risk adjustment, blacks are less intensively treated than whites.

SUBMITTER: Barnato AE

PROVIDER: S-EPMC5757087 | biostudies-literature | 2018 Jan

REPOSITORIES: biostudies-literature

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Publications

The Paradox of End-of-Life Hospital Treatment Intensity among Black Patients: A Retrospective Cohort Study.

Barnato Amber E AE Chang Chung-Chou H CH Lave Judith R JR Angus Derek C DC

Journal of palliative medicine 20171106 1

<h4>Objective</h4>Black patients are more likely than white patients to die in the hospital with intensive care and life-sustaining treatments and less likely to use hospice. Regional concentration of high end-of-life (EOL) treatment intensity practice patterns may disproportionately affect black patients. We calculated and compared race-specific hospital-level EOL treatment intensity in Pennsylvania.<h4>Methods</h4>We conducted a retrospective cohort analysis of Pennsylvania acute care hospital ...[more]

PMID: 29106315

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Project description:ContextHospitals vary substantially in their end-of-life (EOL) treatment intensity. It is unknown if patterns of EOL treatment intensity are consistent across conditions.ObjectivesTo explore the relationship between hospitals' cancer- and non-cancer-specific EOL treatment intensity.MethodsWe conducted a retrospective cohort analysis of Pennsylvania acute care hospital admissions for either cancer or congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD) between 2001 and 2007, linked to vital statistics through 2008. We calculated Bayes's shrunken case-mix standardized (observed-to-expected) ratios of intensive care and life-sustaining treatment use among two EOL cohorts: those prospectively identified at high probability of dying on admission and those retrospectively identified as terminal admissions (decedents). We then summed these to create a hospital-specific prospective and retrospective overall EOL treatment intensity index for cancer vs. CHF/COPD.ResultsThe sample included 207,523 admissions with 15% or greater predicted probability of dying on admission among 172,041 unique adults and 120,372 terminal admissions at 166 hospitals; these two cohorts overlapped by 52,986 admissions. There was substantial variation between hospitals in their standardized EOL treatment intensity ratios among cancer and CHF/COPD admissions. Within hospitals, cancer- and CHF/COPD-specific standardized EOL treatment intensity ratios were highly correlated for intensive care unit (ICU) admission (prospective ρ = 0.81; retrospective ρ = 0.78), ICU lengths of stay (ρ = 0.76; 0.64), mechanical ventilation (ρ = 0.73; 0.73), and hemodialysis (ρ = 0.60; 0.71) and less highly correlated for tracheostomy (ρ = 0.43; 0.53) and gastrostomy (ρ = 0.29; 0.30). Hospitals' overall EOL intensity index for cancer and CHF admissions were correlated (prospective ρ = 0.75; retrospective ρ = 0.75) and had equal group means (P-value = 0.631; 0.699).ConclusionDespite substantial difference between hospitals in EOL treatment intensity, within-hospital homogeneity in EOL treatment intensity for cancer- and non-cancer populations suggests the existence of condition-insensitive institutional norms of EOL treatment.

Project description:ImportanceAlthough hospice use is increasing and patients in the US are increasingly dying at home, racial disparities in treatment intensity at the end of life, including hospice use, remain.ObjectiveTo examine differences between Black and White patients in end-of-life care in a population sample with well-characterized causes of death.Design, setting, and participantsThis study used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, an ongoing population-based cohort study with enrollment between January 25, 2003, and October 3, 2007, with linkage to Medicare claims data. Multivariable logistic regression models were used to examine racial and regional differences in end-of-life outcomes and in stroke mortality among 1212 participants with fee-for-service Medicare who died between January 1, 2013, and December 31, 2015, owing to natural causes and excluding sudden death, with oversampling of Black individuals and residents of Southeastern states in the United States. Initial analyses were conducted in March 2019, and final primary analyses were conducted in February 2020.Main outcomes and measuresThe primary outcomes of interest were hospice use of 3 or more days in the last 6 months of life derived from Medicare claims files. Other outcomes included multiple hospitalizations, emergency department visits, and use of intensive procedures in the last 6 months of life. Cause of death was adjudicated by an expert panel of clinicians using death certificates, proxy interviews, autopsy reports, and medical records.ResultsThe sample consisted of 1212 participants (630 men [52.0%]; 378 Black individuals [31.2%]; mean [SD] age at death, 81.0 [8.6] years) of 2542 total deaths. Black decedents were less likely than White decedents to use hospice for 3 or more days (132 of 378 [34.9%] vs 385 of 834 [46.2%]; P < .001). After stratification by cause of death, substantial racial differences in treatment intensity and service use were found among persons who died of cardiovascular disease but not among patients who died of cancer. In analyses adjusted for cause of death (dementia, cancer, cardiovascular disease, and other) and clinical and demographic variables, Black decedents were significantly less likely to use 3 or more days of hospice (odds ratio [OR], 0.72; 95% CI, 0.54-0.96) and were more likely to have multiple emergency department visits (OR, 1.35; 95% CI, 1.01-1.80) and hospitalizations (OR, 1.39; 95% CI, 1.02-1.89) and undergo intensive treatment (OR, 1.94; 95% CI, 1.40-2.70) in the last 6 months of life compared with White decedents.Conclusions and relevanceDespite the increase in the use of hospice care in recent decades, racial disparities in the use of hospice remain, especially for noncancer deaths. More research is required to better understand racial disparities in access to and quality of end-of-life care.

Project description:ImportanceThere is substantial institutional variability in the intensity of end-of-life care that is not explained by patient preferences. Hospital culture and institutional structures (eg, policies, practices, protocols, resources) might contribute to potentially nonbeneficial high-intensity life-sustaining treatments near the end of life.ObjectiveTo understand the role of hospital culture in the everyday dynamics of high-intensity end-of-life care.Design, setting, and participantsThis comparative ethnographic study was conducted at 3 academic hospitals in California and Washington that differed in end-of-life care intensity based on measures in the Dartmouth Atlas and included hospital-based clinicians, administrators, and leaders. Data were deductively and inductively analyzed using thematic analysis through an iterative coding process.Main outcome and measureInstitution-specific policies, practices, protocols, and resources and their role in the everyday dynamics of potentially nonbeneficial, high-intensity life-sustaining treatments.ResultsA total of 113 semistructured, in-depth interviews (66 women [58.4%]; 23 [20.4%] Asian, 1 [0.9%] Black, 5 [4.4%] Hispanic, 7 [6.2%] multiracial, and 70 [61.9%] White individuals) were conducted with inpatient-based clinicians and administrators between December 2018 and June 2022. Respondents at all hospitals described default tendencies to provide high-intensity treatments that they believed were universal in US hospitals. They also reported that proactive, concerted efforts among multiple care teams were required to deescalate high-intensity treatments. Efforts to deescalate were vulnerable to being undermined at multiple points during a patient's care trajectory by any individual or entity. Respondents described institution-specific policies, practices, protocols, and resources that engendered broadly held understandings of the importance of deescalating nonbeneficial life-sustaining treatments. Respondents at different hospitals reported different policies and practices that encouraged or discouraged deescalation. They described how these institutional structures contributed to the culture and everyday dynamics of end-of-life care at their institution.Conclusions and relevanceIn this qualitative study, clinicians, administrators, and leaders at the hospitals studied reported that they work in a hospital culture in which high-intensity end-of-life care constitutes a default trajectory. Institutional structures and hospital cultures shape the everyday dynamics by which clinicians may deescalate end-of-life patients from this trajectory. Individual behaviors or interactions may fail to mitigate potentially nonbeneficial high-intensity life-sustaining treatments if extant hospital culture or a lack of supportive policies and practices undermine individual efforts. Hospital cultures need to be considered when developing policies and interventions to decrease potentially nonbeneficial, high-intensity life-sustaining treatments.

Project description:To examine inpatient intensive care unit (ICU) and intensive procedure use by race among Medicare decedents, using utilization among survivors for comparison.Retrospective observational analysis of inpatient claims using multivariable hierarchical logistic regression.United States, 1989-1999.Hospitalized Medicare fee-for-service decedents (n = 976,220) and survivors (n = 845,306) aged 65 years or older.Admission to the ICU and use of one or more intensive procedures over 12 months, and, for inpatient decedents, during the terminal admission. Black decedents with one or more hospitalization in the last 12 months of life were slightly more likely than non-blacks to be admitted to the ICU during the last 12 months (49.3% vs. 47.4%, p <.0001) and the terminal hospitalization (41.9% vs. 40.6%, p < 0.0001), but these differences disappeared or attenuated in multivariable hierarchical logistic regressions (last 12 months adjusted odds ratio (AOR) 1.0 [0.99-1.03], p = .36; terminal hospitalization AOR 1.03 [1.0-1.06], p = .01). Black decedents were more likely to undergo an intensive procedure during the last 12 months (49.6% vs. 42.8%, p < .0001) and the terminal hospitalization (37.7% vs, 31.1%, p < .0001), a difference that persisted with adjustment (last 12 months AOR 1.1 [1.08-1.14], p < .0001; terminal hospitalization AOR 1.23 [1.20-1.26], p < .0001). Patterns of differences in inpatient treatment intensity by race were reversed among survivors: blacks had lower rates of ICU admission (31.2% vs. 32.4%, p < .0001; AOR 0.93 [0.91-0.95], p < .0001) and intensive procedure use (36.6% vs. 44.2%; AOR 0.72 [0.70-0.73], p <.0001). These differences were driven by greater use by blacks of life-sustaining treatments that predominate among decedents but lesser use of cardiovascular and orthopedic procedures that predominate among survivors. A hospital's black census was a strong predictor of inpatient end-of-life treatment intensity.Black decedents were treated more intensively during hospitalization than non-black decedents, whereas black survivors were treated less intensively. These differences are strongly associated with a hospital's black census. The causes and consequences of these hospital-level differences in intensity deserve further study.

Dataset Information

The Paradox of End-of-Life Hospital Treatment Intensity among Black Patients: A Retrospective Cohort Study.

Objective

Methods

Results

Conclusions

Publications

The Paradox of End-of-Life Hospital Treatment Intensity among Black Patients: A Retrospective Cohort Study.

Similar Datasets

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