End-of-life hospitalization for African American and non-Latino white nursing home residents: variation by race and a facility's racial composition.
Department of Community Health, Center for Gerontology and Health Care Research, Brown University Medical School, Providence, Rhode Island 02912, USA. Journal of Palliative Medicine
(Impact Factor: 1.91).
03/2005; 8(1):58-68. DOI: 10.1089/jpm.2005.8.58
Hospitalization of nursing home residents at the end of life is common, more so among African Americans. Whether a nursing home's racial mix is associated with hospitalization is unknown.
This study examined the association between race, a nursing home's racial mix, and end-of-life hospitalization.
This was a retrospective cohort study.
Studied were nursing home residents in New York (n = 14,159) and Mississippi (n = 1481) who died in 1995-1996 and had a minimum data set (MDS) assessment within 120 days of death.
The outcome measure was the odds of hospitalization in the last 90 days of life. A variable reflecting a nursing home's proportion of African American residents (in 1995-1996) represented a nursing home's racial mix.
Forty-six percent of African Americans and 32% of whites were hospitalized in the last 90 days of life. After controlling for demographics, diagnoses, function, patient preferences (do-not-resuscitate [DNR]), and facility resources, nursing home residents in facilities having higher proportions of African American residents had greater odds of hospitalization (adjusted odds ratio [AOR] 1.14; 95% confidence interval [CI] 1.10, 1.18 in New York and AOR 1.35; 95% CI 1.24, 1.46 in Mississippi). Age and frailty interacted with race; older African Americans had a 16% greater likelihood (95% CI 1.08, 1.24) of hospitalization, and African Americans with more functional limitations had a 37% (95% CI 1.24, 1.51) greater likelihood of hospitalization than did comparable whites.
It appears higher end-of-life hospitalization rates for African American residents are attributable to the facilities where most reside, and to differential hospitalization of older or more functional limited residents.
Figures in this publication
Available from: Peter J Veazie
- "Prior studies of factors associated with EOL quality of care have focused largely on measures of nursing home capacity and capability ( Carter & Porell, 2003 ; Mor, Papandonatos, & Miller, 2005 ; Troyer & McAuley, 2006 ). Although researchers have readily acknowledged the importance of processes of care in infl uencing EOL quality of care and outcomes, only a handful of empirical studies have been focused on EOL care processes in nursing homes ( Forbes, Bern-Klug, & Gessert, 2000 ; Jenq, Guo, Drickamer, Marottoli, & Reid, 2004 ; McAuley, Buchanan, Travis, Wang, & Kim, 2006 ). "
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ABSTRACT: The objectives of this study were to develop measures of end-of-life (EOL) care processes in nursing homes and to validate the instrument for measuring them.
A survey of directors of nursing was conducted in 608 eligible nursing homes in New York State. Responses were obtained from 313 (51.5% response rate) facilities. Secondary data on structural characteristics of the nursing homes were obtained from the Online Survey Certification and Reporting System. Exploratory factor analyses and internal consistency reliability analyses were performed. Multivariate regression models with fixed and random effects were estimated.
Four EOL process domains were identified-assessment, delivery, communication and coordination of care among providers, and communication with residents and families. The scales measuring these EOL process domains demonstrated acceptable to high internal consistency reliability and face, content, and construct validity. Facilities with more EOL quality assurance or monitoring mechanisms in place and greater emphasis on EOL staff education had better scores on EOL care processes of assessment, communication and coordination among providers, and care delivery. Facilities with better registered nurse and certified nurse aide staffing ratios and those with religious affiliation also scored higher on selected care process measures.
This study offers a new validated tool for measuring EOL care processes in nursing homes. Our findings suggest wide variations in care processes across facilities, which in part may stem from lack of gold standards for EOL practice in nursing homes.
Available from: Susan C Miller
- "The amount and type of information that black residents and their families receive, particularly around end-of-life decisions, may partially account for these findings . Mortality follow-back studies have shown that family members of black decedents were less likely to report that death was expected, even if the resident was highly impaired before death (Williams 2006), and more likely to report problems in physician communication than were family members of white decedents (Welch, Teno, and Mor 2005). There are limitations to this study. "
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ABSTRACT: To examine racial differences in the risk of hospitalization for nursing home (NH) residents.
National NH Minimum Data Set, Medicare claims, and Online Survey Certification and Reporting data from 2000 were merged with independently collected Medicaid policy data.
One hundred and fifty day follow-up of 516,082 long-stay residents.
18.5 percent of white and 24.1 percent of black residents were hospitalized. Residents in NHs with high concentrations of blacks had 20 percent higher odds (95 percent confidence interval [CI]=1.15-1.25) of hospitalization than residents in NHs with no blacks. Ten-dollar increments in Medicaid rates reduced the odds of hospitalization by 4 percent (95 percent CI=0.93-1.00) for white residents and 22 percent (95 percent CI=0.69-0.87) for black residents.
Our findings illustrate the effect of contextual forces on racial disparities in NH care.
Available from: William E Haley
- "Although a number of studies have examined racial differences at the end of life, little is known about the experiences of dual-eligible (Medicare and Medicaid) nursing home residents, a group that is not only the least studied but potentially the most vulnerable. Most previous studies on racial differences in hospice use and hospitalization have focused on cancer patients and general Medicare nursing home or adult populations (Han, Remsburg, & Iwashyna, 2006; Lackan et al., 2004; Mor et al., 2005; Virnig, Moscovice, Durham, & Casey, 2004). A few exceptions have examined dual-eligible older adults or nursing home residents (Enguidanos et al., 2005; Miller et al., 2004). "
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ABSTRACT: We investigated the role of race in predicting the likelihood of using hospice and dying in a hosptial among dual-eligible (Medicare and Medicaid) nursing home residents.
This follow-back cohort study examined factors associated with hospice use and in-hospital death among non-Hispanic Black and non-Hispanic White dual-eligible nursing home residents (N = 30,765) who died in Florida during one of three years: 2000, 2001, or 2002. We used logistic regression models to identify independent predictors of hospice use and in-hospital death.
After we controlled for other factors, Black residents were significantly less likely to use hospice and more likely to die in a hospital. Principal cause of death moderated the relationship between race and hospice use: Black residents were significantly less likely to use hospice than White residents among residents without cancer as principal cause of death, but there was no difference among residents with cancer as cause of death. Further analyses for each racial group revealed that the impact of cause of death in predicting hospice use was greater among Black residents than White residents.
Hospice care offers many benefits, including reduced risk of in-hospital death, but Black nursing home residents are less likely to use hospice and may have different perceptions of need for hospice care compared with White residents. Future research and outreach efforts should focus on developing culturally sensitive, disease-focused end-of-life education and communication interventions that target residents, families, nursing home providers, and physicians.
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