Racial Disparities in Intensity of Care at the End-of-Life: Are Trauma Patients the Same as the Rest?
ABSTRACT Medicare data show Blacks and Hispanics use more health care resources in the last six months of life than Whites. We sought to determine if similar differences exist in trauma patients who died following moderate to severe injury.
We analyzed data from a prospective cohort study of 18 Level 1 and 51 non-trauma centers in 12 states to examine racial/ethnic variation in intensity of care and hospital costs.
Blacks were more likely than Whites to receive critical care consultation RR=1.67 (95% CI, 1.22, 2.30), specialty assessments RR=1.44 (95% CI, 1.12, 1.86) and procedures RR=1.22 (95% CI, 1.00, 150). Hispanics were less likely than Whites to have withdrawal-of-care orders, RR=0.72 (95% CI, 0.53, 0.98).
Among patients who die after trauma, Blacks receive higher intensity of care and Hispanics were less likely to have withdrawal of care orders than others. This suggests racial disparities in patient preferences and provider treatment.
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ABSTRACT: Racial differences in withdrawal of mechanical ventilation (WMV) have been demonstrated among patients with severe neurologic injuries. We ascertained whether such differences might be accounted for by imbalances in socioeconomic status or disease severity, and whether such racial differences impact hospital mortality or result in greater discharge to long-term care facilities. We evaluated WMV among 1885 mechanically ventilated patients with severe neurologic injury (defined as Glasgow Coma Scale <9), excluding those progressing to brain death within the first 48 hours. Withdrawal of mechanical ventilation was less likely in nonwhite patients (22% vs 31%, P < .001). Nonwhites were younger and were more likely to have Medicaid or no insurance, live in ZIP codes with low median household incomes, be unmarried, and have greater illness severity; but after adjustment for these variables, racial difference in WMV persisted (odds ratio, 0.56; 95% confidence interval, 0.42-0.76). Nonwhite patients were more likely to die instead with full support or progress to brain death, resulting in equivalent overall hospital mortality (40% vs 42%, P = .44). Among survivors, nonwhites were more likely to be discharged to long-term care facilities (27% vs 17%, P < .001). Surrogates of nonwhite neurologically injured patients chose WMV less often even after correcting for socioeconomic status and other confounders. This difference in end-of-life decision making does not appear to alter hospital mortality but may result in more survivors left in a disabled state.Journal of critical care 10/2013; 29(1). DOI:10.1016/j.jcrc.2013.08.023 · 2.19 Impact Factor
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ABSTRACT: Objective: To provide a description of communication breakdowns and to identify interventions to improve surgical decision making for elderly patients with serious illness and acute, life-threatening surgical conditions. Background: Communication between surgeons, patients, and surrogates about goals of treatment plays an important and understudied role in determining the surgical interventions elderly patients with serious illness receive. Communication breakdowns may lead to nonbeneficial procedures in acute events near the end of life. Methods: We review the available literature on factors that lead to communication challenges and nonbeneficial surgery at the end of life. We use this review to identify solutions for navigating surgical decision making for seriously ill elderly patients with acute surgical conditions. Results: Surgeon, patient, surrogate, and systemic factors-including time constraints, inadequate provider communication skills and training, uncertainty about prognosis, patient and surrogate anxiety and fear of inaction, and limitations in advance care planning-contribute to communication challenges and nonbeneficial surgery at the end of life. Surgeons could accomplish more effective communication with seriously ill elderly patients if they had a structured, standardized approach to exploring patients' preferences and to integrating those preferences into surgical decisions in the acute setting. Conclusions: Improved communication among surgeons, patients, and surrogates is necessary to ensure that patients receive the care that they want and to avoid nonbeneficial treatment. Further research is needed to learn how to best structure these conversations in the emergency surgical setting.Annals of Surgery 05/2014; 260(6). DOI:10.1097/SLA.0000000000000721 · 8.33 Impact Factor
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ABSTRACT: BACKGROUND: The use of "withdrawal of care" and impact upon outcomes among patients with subarachnoid hemorrhage (SAH) is not well studied. OBJECTIVE: To identify the rate and determinants of "withdrawal of care" among SAH patients. METHODS: We determined the frequency of "withdrawal of care" and compared the demographic, clinical characteristics, and in-hospital outcomes among patients with SAH stratified by use of "withdrawal of care." RESULTS: "Withdrawal of care" during hospitalization was instituted in 8912 (3.4%) of the 266,067 patients with SAH. In the stepwise logistic regression, age > 65 (odds ratio [OR] 4.5, 95% confidence interval [95% CI] 3.3-6.1), women (OR 1.2, 95% CI 1.0-1.3), African American (OR 0.7, 95% CI 0.5-0.8), Hispanic ethnicity (OR 0.4, 95% CI 0.3-0.6), renal failure (OR 1.6, 95% CI 1.2-1.9), intracerebral hemorrhage (OR 2.0, 95% CI 1.7-2.4, All Patient Refined Diagnosis-Related Groups severity score of extreme loss of function (OR 40.1, 95% CI 6.0-270.7), All Patient Refined Diagnosis-Related Groups severity score of severe loss of function (OR 15.0, 95% CI 2.1-103.8), insurance status of private health maintenance organization (OR 0.7, 95% CI 0.5-0.9), and hospital region south United States (OR 0.7, 95% CI 0.5-0.8), were significant predictors of "withdrawal of care" among patients with SAH. In-hospital mortality was significantly greater, but mean hospitalization charges and length of stay were significantly lower among those with "withdrawal of care." CONCLUSIONS: Although "withdrawal of care" was effective in limiting hospital charges and resource use, caution is needed to avoid disproportionately high mortality. The prominent relationship between race/ethnicity, insurance status, and hospital location with "withdrawal of care" raises concerns that factors other than severity of disease influence decision making.World Neurosurgery 07/2014; 82(5). DOI:10.1016/j.wneu.2014.07.008 · 2.42 Impact Factor