Racial Disparities in Intensity of Care at the End-of-Life: Are Trauma Patients the Same as the Rest?

ArticleinJournal of Health Care for the Poor and Underserved 23(2):857-74 · May 2012with7 Reads
DOI: 10.1353/hpu.2012.0064 · Source: PubMed
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.
    • "Often life and death decisions are focused around quality of life and severe disability [2]. General population based and disease-specific studies in the US have consistently shown that patients of Black and Hispanic ethnicities, are less likely to choose hospice care and less likely to have Do Not Resuscitate (DNR) orders at the end of life.3456 The reasons for these differences are unclear but most likely involve a complex interaction of social, educational, religious, and cultural issues. "
    [Show abstract] [Hide abstract] ABSTRACT: It is common for patients who die from subarachnoid hemorrhage to have a focus on comfort measures at the end of life. The potential role of ethnicity in end-of-life decisions after brain injury has not been extensively studied. Patients with subarachnoid hemorrhage were prospectively followed in an observational database. Demographic information including ethnicity was collected from medical records and self-reported by patients or their family. Significant in-hospital events including do-not-resuscitate orders, comfort measures only orders (CMO; care withheld or withdrawn), and mortality were recorded prospectively. 1255 patients were included in our analysis: 650 (52 %) were White, 387 (31 %) Hispanic, and 218 (17 %) Black. Mortality was similar between the groups. CMO was more commonly observed in Whites (14 %) compared to either Blacks (10 %) or Hispanics (9 %) (p = 0.04). In a multivariate analysis controlling for age and Hunt-Hess grade, Hispanics were less likely to have CMO than Whites (OR, 0.6; 95 %CI, 0.4-0.9; p = 0.02). Of the 229 patients who died, 77 % of Whites had CMO compared to 54 % of Blacks and 49 % of Hispanics (p < 0.01). In a multivariate analysis, Blacks (OR, 0.3; 95 %CI, 0.2-0.7; p < 0.01) and Hispanics (OR, 0.3; 95 %CI, 0.2-0.6; p < 0.01) were less likely to die with CMO orders than Whites. After subarachnoid hemorrhage, Blacks and Hispanics are less likely to die with CMO orders than Whites. Further research to confirm and investigate the causes of these ethnic differences should be performed.
    Full-text · Article · Dec 2014
  • Full-text · Conference Paper · Apr 2012
  • [Show abstract] [Hide abstract] 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.
    Article · Oct 2013
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