Race and residence: intercounty variation in black-white differences in hospice use

Naming racism as a root cause of inequities in palliative care research: a scoping review

BACKGROUND

Racial and ethnic inequities in palliative care are well-established. The way researchers design and interpret studies investigating race- and ethnicity-based disparities has future implications on the interventions aimed to reduce these inequities. If racism is not discussed when contextualizing findings, it is less likely to be addressed and inequities will persist.

OBJECTIVE

To summarize the characteristics of 12 years of academic literature that investigates race- or ethnicity-based disparities in palliative care access, outcomes and experiences, and determine the extent to which racism is discussed when interpreting findings.

METHODS

Following Arksey & O'Malley's methodology for scoping reviews, we searched bibliographic databases for primary, peer reviewed studies globally, in all languages, that collected race or ethnicity variables in a palliative care context (January 1, 2011 to October 17, 2023). We recorded study characteristics and categorized citations based on their research focus-whether race or ethnicity were examined as a major focus (analyzed as a primary independent variable or population of interest) or minor focus (analyzed as a secondary variable) of the research purpose, and the interpretation of findings-whether authors directly or indirectly discussed racism when contextualizing the study results.

RESULTS

We identified 3000 citations and included 181 in our review. Of these, most were from the United States (88.95%) and examined race or ethnicity as a major focus (71.27%). When interpreting findings, authors directly named racism in 7.18% of publications. They were more likely to use words closely associated with racism (20.44%) or describe systemic or individual factors (41.44%). Racism was directly named in 33.33% of articles published since 2021 versus 3.92% in the 10 years prior, suggesting it is becoming more common.

CONCLUSION

While the focus on race and ethnicity in palliative care research is increasing, there is room for improvement when acknowledging systemic factors - including racism - during data analysis. Researchers must be purposeful when investigating race and ethnicity, and identify how racism shapes palliative care access, outcomes and experiences of racially and ethnically minoritized patients.

The Association Between Race and Place of Death Among Persons With Dementia

CONTEXT

Little is known about racial differences in place of death for persons with dementia (PWD), who may be especially vulnerable to receiving care at end of life that is not concordant with their goals or that places higher burden on caregivers.

OBJECTIVES

To determine if there are racial and ethnic differences in place of death among PWD.

METHODS

We analyzed data from the nationally representative National Health and Aging Trends study. Participants were included if they had probable dementia as defined by a previously validated algorithm and died between 2012 and 2020. Race and ethnicity were self-reported. Place of death was obtained from post-mortem interviews with bereaved caregivers.

RESULTS

The sample included 993 decedents with dementia (81.4% white; 11.0% black, 7.6% hispanic). A higher percentage of black and hispanic decedents died in the hospital (30.3% and 32.8%, respectively) compared to white decedents (19.0%). A higher percentage of white decedents died in the nursing home (31.0%) than black (22.4%) or hispanic decedents (15.0%) In adjusted analyses, black decedents had a higher odds of hospital death (AOR 1.50; 95% CI 1.01, 2.24) compared to white decedents, with similar trends found for hispanic decedents.

CONCLUSION

We found racial and ethnic differences in location of death for PWD, with black and hispanic PWD more likely to die in the hospital compared to white PWD. More research is needed to determine if the differences found represent goal concordant care or rather lack of access to high quality of care at the end of life.

Family as a Bridge to Improve Meaning in Latinx Individuals Coping with Cancer

Background:

Family and meaning-making resources are culturally congruent and help support Latinx coping with cancer.

Objectives:

To explore Latinx advanced cancer patients' perspectives on the role of family and meaning/purpose in adjustment to advanced cancer.

Methods:

A qualitative study was conducted. In-depth interviews were performed and transcripts were analyzed using the method from applied thematic analysis.

Setting/Subject:

Participants were patients with any advanced cancer diagnosis, recruited from Memorial Sloan Kettering Cancer Center (MSKCC), New York; Lincoln Medical Center (LMC), New York; and Ponce Health Science University (PHSU), Puerto Rico.

Measurements:

Sociodemographic and semistructured interview.

Results:

N = 24 in-depth interviews were completed by Latinx advanced cancer patients (Stage III and IV). When evaluating patients' perspectives on the role of family and meaning/purpose in adjustment to advanced cancer, the team generated three categories: (1) family support, (2) family communication, and (3) include support for the family. Many patients reported the importance of family as a source of meaning and social support in the process of cancer diagnosis and treatment. They also reported communication as central to process information and planning. Also, participants describe their desire to incorporate family members into therapy and for encouraging them to seek counseling.

Conclusions:

Results highlight the need to include syntonic cultural values such as family and meaning for Latinx individuals coping with advanced cancer in psychological interventions.

A Decade of Studying Drivers of Disparities in End-of-Life Care for Black Americans: Using the NIMHD Framework for Health Disparities Research to Map the Path Ahead

OBJECTIVE

The purpose of this paper is to provide a review of the existing literature on racial disparities in quality of palliative and end-of-life care and to demonstrate gaps in the exploration of underlying mechanisms that produce these disparities.

BACKGROUND

Countless studies over several decades have revealed that our healthcare system in the United States consistently produces poorer quality end-of-life care for Black compared with White patients. Effective interventions to reduce these disparities are sparse and hindered by a limited understanding of the root causes of these disparities.

METHODS

We searched PubMed, CINAHL and PsychInfo for research manuscripts that tested hypotheses about causal mechanisms for disparities in end-of-life care for Black patients. These studies were categorized by domains outlined in the National Institute of Minority Health and Health Disparities (NIMHD) framework, which are biological, behavioral, physical/built environment, sociocultural and health care systems domains. Within these domains, studies were further categorized as focusing on the individual, interpersonal, community or societal level of influence.

RESULTS

The majority of the studies focused on the Healthcare System and Sociocultural domains. Within the Health Care System domain, studies were evenly distributed among the individual, interpersonal, and community level of influence, but less attention was paid to the societal level of influence. In the Sociocultural domain, most studies focused on the individual level of influence. Those focusing on the individual level of influence tended to be of poorer quality.

CONCLUSIONS

The sociocultural environment, physical/built environment, behavioral and biological domains remain understudied areas of potential causal mechanisms for racial disparities in end-of-life care. In the Healthcare System domain, social influences including healthcare policy and law are understudied. In the sociocultural domain, the majority of the studies still focused on the individual level of influence, missing key areas of research in interpersonal discrimination and local and societal structural discrimination. Studies that focus on individual factors should be better screened to ensure that they are of high quality and avoid stigmatizing Black communities.

Application of Critical Race Theory in Palliative Care Research: A Scoping Review

CONTEXT

Structural racism negatively impacts individuals and populations. In the medical literature, including that of palliative care, structural racism's influence on interracial differences in outcomes remains poorly examined. Examining the contribution of structural racism to outcomes is paramount to promoting equity.

OBJECTIVES

We examined portrayals of race and racial differences in outcomes in the palliative care literature and created a framework using critical race theory (CRT) to aid in this examination.

METHODS

We reviewed the CRT literature and iteratively developed a rubric to examine when and how differences between races are described. Research articles published in The Journal of Pain and Symptom Management presenting empiric data specifically including findings about racial differences were examined independently by three reviewers using the rubric.

RESULTS

Fifty-seven articles met inclusion criteria. Articles that specifically described racial differences were common in the topic areas of quality (75% of articles), hospice (53%), palliative care services (40%) and spirituality/religion (40%). The top three reasons posited for racial differences were patient preference (26%), physician bias (23%), and cultural barriers (21%). Using the CRT rubric we found that 65% of articles posited that a racial difference was something that needed to be rectified, while articles rarely provided narrative (5%) or other data on perspectives of people of color (11%) to explain assumptions about differences.

CONCLUSION

Palliative care research frequently highlights racial differences in outcomes. Articles that examine racial differences often assume that differences need to be fixed but posit reasons for differences without the narratives of those most affected by them.

Cultural adaptation of meaning-centered psychotherapy for latino families: a protocol

INTRODUCTION

Literature suggests couple-based interventions that target quality of life and communication can lead to positive outcomes for patients with cancer and their partners. Nevertheless, to date, an intervention to address the needs of Latino families coping with advanced cancer has not been developed. Meta-analytic evidence suggests that culturally adapted evidenced-based intervention targeting a specific cultural group is four times more effective. Our goal is to culturally adapt a novel psychosocial intervention protocol entitled 'Caregivers-Patients Support to Latinx coping advanced-cancer' (CASA). We hypothesised that combine two evidence-based interventions and adapting them, we will sustain a sense of meaning and improving communication as patients approach the end of life among the patient-caregiver dyad.

METHODS AND ANALYSIS

To culturally adapt CASA, we will follow an innovative hybrid research framework that combines elements of an efficacy model and best practices from the ecological validity model, adaptation process model and intervention mapping. As a first step, we adapt a novel psychosocial intervention protocol entitled protocol entitled 'Caregivers-Patients Support to Latinx coping advanced-cancer' (CASA). The initial CASA protocol integrates two empirically based interventions, meaning-centred psychotherapy and couple communication skills training. This is an exploratory and prepilot study, and it is not necessary for a size calculation. However, based on recommendations for exploratory studies of this nature, a priori size of 114 is selected. We will receive CASA protocol feedback (phase 1b: refine) by conducting 114 questionnaires and 15 semistructured interviews with patients with advanced cancer and their caregivers. The primary outcomes of this study will be identifying the foundational information needed to further the develop the CASA (phase IIa: proof-of-concept and phase IIb: pilot study).

ETHICS AND DISSEMINATION

The Institutional Review Board of Ponce Research Institute approved the study protocol #1907017527A002. Results will be disseminated through peer-reviewed publications.

Palliative Care Consultation Reduces Heart Failure Transitions: A Matched Analysis

Background

Palliative care supports quality of life, symptom control, and goal setting in heart failure (HF) patients. Unlike hospice, palliative care does not restrict life‐prolonging therapy. This study examined the association between palliative care during hospitalization for HF on the subsequent transitions and procedures.

Methods and Results

Veterans admitted to hospitals with HF from 2010 to 2015 were randomly selected for the Veterans Administration External Peer Review Program. Variables pertaining to demographic, clinical, laboratory, and usage were captured from Veterans Administration electronic records. Patients receiving hospice services before admission were excluded. Patients who received palliative care were propensity matched to those who did not. The primary outcomes were whether the patient experienced transitions or procedures in the 6 months after admission. Transitions included multiple readmissions (≥2) or intensive care admissions and procedures included mechanical ventilation, pacemaker implantation, or defibrillator implantation. Among 57 182 hospitalized HF patients, 1431 received palliative care, and were well matched to 1431 without (standardized mean differences ≤ ±0.05 on all matched variables). Palliative care was associated with significantly fewer multiple rehospitalizations (30.9% versus 40.3%, P<0.001), mechanical ventilation (2.8% versus 5.4%, P=0.004), and defibrillator implantation (2.1% versus 3.6%, P=0.01). After adjustment for facility fixed effects, palliative care consultation was associated with a significantly reduced hazard of multiple readmissions (adjusted hazard ratio=0.73, 95% CI, 0.64–0.84) and mechanical ventilation (adjusted hazard ratio=0.76, 95% CI, 0.67–0.87).

Conclusions

Palliative care during HF admissions was associated with fewer readmissions and less mechanical ventilation. When available, engagement of HF patients and caregivers in palliative care for symptom control, quality of life, and goals of care discussions may be associated with reduced rehospitalizations and mechanical ventilation.

"It's Like a Death Sentence but It Really Isn't" What Patients and Families Want to Know About Hospice Care When Making End-of-Life Decisions

BACKGROUND

Hospice is underutilized, due to both lack of initiation from patients and late referral from clinicians. Prior research has suggested the reasons for underuse are multifactorial, including clinician and patient lack of understanding, misperceptions about the nature of hospice care, and poor communication during end-of-life discussions about hospice care. Little is known about the decisional needs of patients and families engaging in hospice decision-making.

OBJECTIVES

To understand the decisional needs of patients and families making decisions about hospice care.

METHODS

We conducted focus groups with family caregivers and hospice providers and one-on-one interviews with patients considering or enrolled in hospice care. We identified participants through purposeful and snowball sampling methods. All interviews were transcribed verbatim and analyzed using a grounded theory approach.

RESULTS

Four patients, 32 family caregivers, and 27 hospice providers participated in the study. Four main themes around decisional needs emerged from the interviews and focus groups: (1) What is hospice care?; (2) Why might hospice care be helpful?; (3) Where is hospice care provided?; and (4) How is hospice care paid for?

DISCUSSION

Hospice may not be the right treatment choice for all with terminal illness. Our study highlights where patients' and families' understanding could be enhanced to assure that they have the opportunity to benefit from hospice, if they so desire.

What do family caregivers know about palliative care? Results from a national survey

OBJECTIVE

Despite their key role in caring for individuals with serious, chronic illness, there have been no national studies examining family caregiver awareness and perceptions of palliative care. Hence, our objectives were to ascertain level of knowledge of palliative care among U.S. family caregivers and describe demographic variation in awareness and perceptions of palliative care.

METHOD

Using the 2018 National Cancer Institute Health Information National Trends Survey, we identified unpaid family caregivers caring or making healthcare decisions for someone with a medical, behavioral, disability, or other condition. Respondents were asked about their awareness of the term "palliative care" and, if aware, how much they agreed with statements representing common (mis)perceptions about palliative care (e.g., "Palliative care is the same as hospice").

RESULT

More than one-half of caregivers (55%) had "never heard" of palliative care; 19.2% knew what palliative care was and "could explain it to someone else." In adjusted models, racial minorities (vs. whites) and those without a college degree were less likely to have heard of palliative care. Among those aware of palliative care, ~40% "strongly" or "somewhat" agreed that "Palliative care is the same as hospice"; another 10.5% "didn't know." Similarly, 40% reported that "When I think of palliative care, I automatically think of death."

SIGNIFICANCE OF RESULTS

One-half of family caregivers of adults with serious chronic illness have never heard of palliative care. Even among those who had heard of palliative care, the majority do not distinguish it from hospice care and death. Given the role family caregivers may play in decisions to access palliative care, public messaging efforts are needed to clarify palliative care services in a way that is patient- and family-centered.

Use of Hospital Referral Regions in Evaluating End-of-Life Care

Background: Hospital referral regions (HRRs) are often used to characterize inpatient referral patterns, but it is unknown how well these geographic regions are aligned with variation in Medicare-financed hospice care, which is largely provided at home. Objective: Our objective was to characterize the variability in hospice use rates among elderly Medicare decedents by HRR and county. Methods: Using 2014 Master Beneficiary File for decedents 65 and older from North and South Carolina, we applied Bayesian mixed models to quantify variation in hospice use rates explained by HRR fixed effects, county random effects, and residual error among Medicare decedents. Results: We found HRRs and county indicators are significant predictors of hospice use in NC and SC; however, the relative variation within HRRs and associated residual variation is substantial. On average, HRR fixed effects explained more variation in hospice use rates than county indicators with a standard deviation (SD) of 10.0 versus 5.1 percentage points. The SD of the residual error is 5.7 percentage points. On average, variation within HRRs is about half the variation between regions (52%). Conclusions: The magnitude of unexplained residual variation in hospice use for NC and SC suggests that novel, end-of-life-specific service areas should be developed and tested to better capture geographic differences and inform research, health systems, and policy.

End-of-Life Care in Patients Exposed to Home-Based Palliative Care vs Hospice Only

OBJECTIVES

The current evidence base regarding the effectiveness of home-based palliative care (HomePal) on outcomes of importance to multiple stakeholders remains limited. The purpose of this study was to compare end-of-life care in decedents who received HomePal with two cohorts that either received hospice only (HO) or did not receive HomePal or hospice (No HomePal-HO).

DESIGN

Retrospective cohorts from an ongoing study of care transition from hospital to home. Data were collected from 2011 to 2016.

SETTING

Kaiser Permanente Southern California.

PARTICIPANTS

Decedents 65 and older who received HomePal (n = 7177) after a hospitalization and two comparison cohorts (HO only = 25 102; No HomePal-HO = 22 472).

MEASUREMENTS

Utilization data were extracted from administrative, clinical, and claims databases, and death data were obtained from state and national indices. Days at home was calculated as days not spent in the hospital or in a skilled nursing facility (SNF).

RESULTS

Patients who received HomePal were enrolled for a median of 43 days and had comparable length of stay on hospice as patients who enrolled only in hospice (median days = 13 vs 12). Deaths at home were comparable between HomePal and HO (59% vs 60%) and were higher compared with No HomePal-HO (16%). For patients who survived at least 6 months after HomePal admission (n = 2289), the mean number of days at home in the last 6 months of life was 163 ± 30 vs 161 ± 30 (HO) vs 149 ± 40 (No HomePal-HO). Similar trends were also noted for the last 30 days of life, 25 ± 8 (HomePal, n = 5516), 24 ± 8 (HO), and 18 ± 11 (No HomePal-HO); HomePal patients had a significantly lower risk of hospitalizations (relative risk [RR] = .58-.87) and SNF stays (RR = .32-.77) compared with both HO and No HomePal-HO patients.

CONCLUSION

Earlier comprehensive palliative care in patients' home in place of or preceding hospice is associated with fewer hospitalizations and SNF stays and more time at home in the final 6 months of life. J Am Geriatr Soc, 2019.

Health Disparities in Hospice Utilization and Length of Stay in a Diverse Population With Lung Cancer

Background:

Lung cancer is the leading cause of cancer deaths globally. Individuals are diagnosed at an advanced stage with limited life expectancy.

Objectives:

To explore potential health disparities in hospice utilization and length of stay (LOS) in a diverse sample of patients with lung cancer.

Methods:

Demographic and clinical information as well as data for hospice utilization and LOS was extracted from electronic health records. Data were analyzed using descriptive statistics, χ2 tests, and an analysis of variance test.

Results:

Data from 242 patients were analyzed. In the sample, 33% (n = 80) were Black and 51% (n = 124) lived in a rural county. At the time of data collection, 67% of the sample was deceased and 36% (n = 86) chose to enroll in hospice. No disparities were found for race, age, gender, or rural/urban dwellers in hospice enrollment. No disparities were found for race, gender, or rural/urban dwellers for hospice LOS. Age was associated with hospice LOS ( P = .004). Those who were older were more likely to have a longer LOS.

Conclusion:

Hospice utilization and LOS were low for all groups with lung cancer in a geographically and racially diverse region of the United States. Given the rates of mortality in lung cancer, discussions about the goals and benefits of hospice care may be beneficial and should be part of an ongoing dialogue throughout the disease trajectory.

Determinants and Outcomes of Hospice Utilization Among Patients with Advance-Staged Hepatocellular Carcinoma in a Veteran Affairs Population

BACKGROUND

Hospice provides integrative palliative care for advance-staged hepatocellular carcinoma (HCC) patients, but hospice utilization in HCC patients in the USA is not clearly understood.

AIMS

We examined hospice use and subsequent clinical course in advance-staged HCC patients.

METHODS

We conducted a retrospective study on a national, Veterans Affairs cohort with stage C or D HCC. We evaluated demographics, clinical factors, treatment, and clinical course in relation to hospice use.

RESULTS

We identified 814 patients with advanced HCC, of whom 597 (73.3%) used hospice. Oncologist management consistently predicted hospice use, irrespective of HCC treatment [no treatment: OR 2.25 (1.18-4.3), treatment: OR 1.80 (1.10-2.95)]. Among patients who received HCC treatment, hospice users were less likely to have insurance beyond VA benefits (47.2 vs. 60.0%, p = 0.01). Among patients without HCC treatment, hospice users were older (62.2 [17.2] vs. 60.2 [14.0] years, p = 0.05), white (62.1 vs. 52.9%, p = 0.01), resided in the Southern USA (39.5 vs. 31.8%, p = 0.05), and had a performance score ≥ 3 (41.9 vs. 31.8%, p = 0.01). The median time from hospice entry to death or end of study was 1.05 [2.96] months for stage C and 0.53 [1.18] months for stage D patients.

CONCLUSIONS

26.7% advance-staged HCC patients never entered hospice, representing potential missed opportunities for improving end-of-life care. Age, race, location, performance, insurance, and managing specialty can predict hospice use. Differences in managing specialty and short-term hospice use suggest that interventions to optimize early palliative care are necessary.

Engaging patients and families to create a feasible clinical trial integrating palliative and heart failure care: results of the ENABLE CHF-PC pilot clinical trial

BACKGROUND

Early palliative care (EPC) is recommended but rarely integrated with advanced heart failure (HF) care. We engaged patients and family caregivers to study the feasibility and site differences in a two-site EPC trial, ENABLE CHF-PC (Educate, Nurture, Advise, Before Life Ends Comprehensive Heartcare for Patients and Caregivers).

METHODS

We conducted an EPC feasibility study (4/1/14-8/31/15) for patients with NYHA Class III/IV HF and their caregivers in academic medical centers in the northeast and southeast U.S. The EPC intervention comprised: 1) an in-person outpatient palliative care consultation; and 2) telephonic nurse coach sessions and monthly calls. We collected patient- and caregiver-reported outcomes of quality of life (QOL), symptom, health, anxiety, and depression at baseline, 12- and 24-weeks. We used linear mixed-models to assess baseline to week 24 longitudinal changes.

RESULTS

We enrolled 61 patients and 48 caregivers; between-site demographic differences included age, race, religion, marital, and work status. Most patients (69%) and caregivers (79%) completed all intervention sessions; however, we noted large between-site differences in measurement completion (38% southeast vs. 72% northeast). Patients experienced moderate effect size improvements in QOL, symptoms, physical, and mental health; caregivers experienced moderate effect size improvements in QOL, depression, mental health, and burden. Small-to-moderate effect size improvements were noted in patients' hospital and ICU days and emergency visits.

CONCLUSIONS

Between-site demographic, attrition, and participant-reported outcomes highlight the importance of intervention pilot-testing in culturally diverse populations. Observations from this pilot feasibility trial allowed us to refine the methodology of an in-progress, full-scale randomized clinical efficacy trial.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03177447 (retrospectively registered, June 2017).

Race/Ethnicity as a Predictor for Location of Death in Patients With Acute Neurovascular Events

BACKGROUND

Site of death is an important quality indicator for patients with terminal illness. Racial and ethnic disparities exist in the quality of end-of-life care. This study explores the site of death of patients admitted for and dying of complications of acute neurovascular events in a hospital network in an urban, low-income, predominantly minority community.

METHODS

This is a retrospective cohort study of patients admitted to 1 of 3 general hospitals that are part of an academic medical center in Bronx, New York, with the diagnosis of acute ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage who died during the index admission or were discharged with hospice services. The main outcome was location of death (palliative care inpatient unit [IPU] at the medical center or hospice services at discharge vs death on any other IPU).

RESULTS

A total of 655 patients admitted with acute neurovascular events from January 1, 2009, to March 1, 2015, died or were discharged with hospice services and were included in the analysis. Of those patients, 238 (36.3%) were black, 233 (35.5%) were Hispanic, and 184 (28.1%) were white. A total of 178 (24.4%) died on the palliative care unit or were discharged with hospice services, including 55 black patients (23.1%), 52 (28.3%) white patients, and 53 (22.7%) Hispanic patients. These differences were not statistically significant, even when controlling for confounders.

CONCLUSION

This study did not show a difference in site of death in our institution by race or ethnicity, which is considered an important quality end-of-life care metric.

Racial and Ethnic Differences in End-of-Life Medicare Expenditures

OBJECTIVES

To determine to what extent demographic, social support, socioeconomic, geographic, medical, and End-of-Life (EOL) planning factors explain racial and ethnic variation in Medicare spending during the last 6 months of life.

DESIGN

Retrospective cohort study.

SETTING

Health and Retirement Study (HRS).

PARTICIPANTS

Decedents who participated in HRS between 1998 and 2012 and previously consented to survey linkage with Medicare claims (N = 7,105).

MEASUREMENTS

Total Medicare expenditures in the last 180 days of life according to race and ethnicity, controlling for demographic factors, social supports, geography, illness burden, and EOL planning factors, including presence of advance directives, discussion of EOL treatment preferences, and whether death had been expected.

RESULTS

The analysis included 5,548 (78.1%) non-Hispanic white, 1,030 (14.5%) non-Hispanic black, and 331 (4.7%) Hispanic adults and 196 (2.8%) adults of other race or ethnicity. Unadjusted results suggest that average EOL Medicare expenditures were $13,522 (35%, P < .001) more for black decedents and $16,341 (42%, P < .001) more for Hispanics than for whites. Controlling for demographic, socioeconomic, geographic, medical, and EOL-specific factors, the Medicare expenditure difference between groups fell to $8,047 (22%, P < .001) more for black and $6,855 (19%, P < .001) more for Hispanic decedents than expenditures for non-Hispanic whites. The expenditure differences between groups remained statistically significant in all models.

CONCLUSION

Individuals-level factors, including EOL planning factors do not fully explain racial and ethnic differences in Medicare spending in the last 6 months of life. Future research should focus on broader systemic, organizational, and provider-level factors to explain these differences.

Are Hospice Admission Practices Associated With Hospice Enrollment for Older African Americans and Whites?

CONTEXT

Hospices that enroll patients receiving expensive palliative therapies may serve more African Americans because of their greater preferences for aggressive end-of-life care.

OBJECTIVES

Examine the association between hospices' admission practices and enrollment of African Americans and whites.

METHODS

This was a cross-sectional study of 61 North and South Carolina hospices. We developed a hospice admission practices scale; higher scores indicate less restrictive practices, that is, greater frequency with which hospices admitted those receiving chemotherapy, inotropes, and so forth. In separate multivariate analyses for each racial group, we examined the relationship between the proportion of decedents (age ≥ 65) served by a hospice in their service area (2008 Medicare Data) and admission practices while controlling for health care resources (e.g., hospital beds) and market concentration in the area, ownership, and budget.

RESULTS

Nonprofit hospices and those with larger budgets reported less restrictive admission practices. In bivariate analyses, hospices with less restrictive admission practices served a larger proportion of patients in both racial groups (P < 0.001). However, in the multivariate models, nonprofit ownership and larger budgets but not admission practices predicted the outcome.

CONCLUSION

Hospices with larger budgets served a greater proportion of African Americans and whites in their service area. Although larger hospices reported less restrictive admission practices, they also may have provided other services that may be important to patients regardless of race, such as more in-home support or assistance with nonmedical expenses, and participated in more outreach activities increasing their visibility and referral base. Future research should explore factors that influence decisions about hospice enrollment among racially diverse older adults.

Spousal Characteristics and Older Adults' Hospice Use: Understanding Disparities in End-of-Life Care

BACKGROUND

Hospice use has been shown to benefit quality of life for patients with terminal illness and their families, with further evidence of cost savings for Medicare and other payers. While disparities in hospice use by patient diagnosis, race, and region are well documented and attention to the role of family members in end-of-life decision-making is increasing, the influence of spousal characteristics on the decision to use hospice is unknown.

OBJECTIVES

To determine the association between spousal characteristics and hospice use.

DESIGN

We used data from the Health and Retirement Study (HRS), a prospective cohort study, linked to the Dartmouth Atlas of Health Care and Medicare claims.

SETTING

National study of 1567 decedents who were married or partnered at the time of death (2000-2011).

MEASURES

Hospice use at least 1 day in the last year of life as measured via Medicare claims data. Spousal factors (e.g., education and health status) measured via survey.

RESULTS

In multivariate models controlling for patient factors and regional variation, spouses with lower educational attainment than their deceased spouse had decreased likelihood of hospice use (odds ratio [OR] = 0.58; 95% confidence interval [CI] = 0.40-0.82). Health of the spouse was not significantly associated with likelihood of decedent hospice use in adjusted models.

IMPLICATIONS

Although the health of the surviving spouse was not associated with hospice use, their educational level was a predictor of hospice use. Spousal and family characteristics, including educational attainment, should be examined further in relation to disparities in hospice use. Efforts to increase access to high-quality end-of-life care for individuals with serious illness must also address the needs and concerns of caregivers and family.

The Desires of Their Hearts: The Multidisciplinary Perspectives of African Americans on End-of-Life Care in the African American Community

BACKGROUND

Studies have identified racial differences in advance care planning and use of hospice for care at the end of life. Multiple reasons for underuse among African American patients and their families have been proposed and deserve further exploration.

OBJECTIVE

The goal of this study was to examine perceptions of advance care planning, palliative care, and hospice among a diverse sample of African Americans with varying degrees of personal and professional experience with end-of-life care and use these responses to inform a culturally sensitive intervention to promote awareness of these options.

METHODS

Semistructured interviews and focus groups were conducted with African Americans who had varying degrees of experience and exposure to end-of-life care both personally and professionally. We conducted in-depth qualitative analyses of these interviews and focus group transcripts and determined that thematic saturation had been achieved.

RESULTS

Several themes emerged. Participants felt that advance care planning, palliative care, and hospice can be beneficial to African American patients and their families but identified specific barriers to completion of advance directives and hospice enrollment, including lack of knowledge, fear that these measures may hasten death or cause providers to deliver inadequate care, and perceived conflict with patients' faith and religious beliefs. Providers described approaches they use to address these barriers in their practices.

CONCLUSION

Findings, which are consistent with and further elucidate those identified from previous research, will inform design of a culturally sensitive intervention to increase awareness and understanding of advance care planning, palliative care, and hospice among members of the African American community.

Racial Differences in Processes of Care at End of Life in VA Medical Centers: Planned Secondary Analysis of Data from the BEACON Trial

BACKGROUND

Racial differences exist for a number of health conditions, services, and outcomes, including end-of-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.