Racial disparity in advance care planning

Disparities of care for African-Americans and Caucasians with community-acquired pneumonia: a retrospective cohort study

BACKGROUND

African-Americans admitted to U.S. hospitals with community-acquired pneumonia (CAP) are more likely than Caucasians to experience prolonged hospital length of stay (LOS), possibly due to either differential treatment decisions or patient characteristics.

METHODS

We assessed associations between race and outcomes (Intensive Care Unit [ICU] variables, LOS, 30-day mortality) for African-American or Caucasian patients over 65 years hospitalized in the Veterans Health Administration (VHA) with CAP (2002-2007). Patients admitted to the ICU were analyzed separately from those not admitted to the ICU. VHA patients who died within 30 days of discharge were excluded from all LOS analyses. We used chi-square and Fisher's exact statistics to compare dichotomous variables, the Wilcoxon Rank Sum test to compare age by race, and Cox Proportional Hazards Regression to analyze hospital LOS. We used separate generalized linear mixed-effect models, with admitting hospital as a random effect, to examine associations between patient race and the receipt of guideline-concordant antibiotics, ICU admission, use of mechanical ventilation, use of vasopressors, LOS, and 30-day mortality. We defined statistical significance as a two-tailed p

RESULTS

Of 40,878 patients, African-Americans (n = 4,936) were less likely to be married and more likely to have a substance use disorder, neoplastic disease, renal disease, or diabetes compared to Caucasians. African-Americans and Caucasians were equally likely to receive guideline-concordant antibiotics (92% versus 93%, adjusted OR = 0.99; 95% CI = 0.81 to 1.20) and experienced similar 30-day mortality when treated in medical wards (adjusted OR = 0.98; 95% CI = 0.87 to 1.10). African-Americans had a shorter adjusted hospital LOS (adjusted HR = 0.95; 95% CI = 0.92 to 0.98). When admitted to the ICU, African Americans were as likely as Caucasians to receive guideline-concordant antibiotics (76% versus 78%, adjusted OR = 0.99; 95% CI = 0.81 to 1.20), but experienced lower 30-day mortality (adjusted OR = 0.82; 95% CI = 0.68 to 0.99) and shorter hospital LOS (adjusted HR = 0.84; 95% CI = 0.76 to 0.93).

CONCLUSIONS

Elderly African-American CAP patients experienced a survival advantage (i.e., lower 30-day mortality) in the ICU compared to Caucasians and shorter hospital LOS in both medical wards and ICUs, after adjusting for numerous baseline differences in patient characteristics. There were no racial differences in receipt of guideline-concordant antibiotic therapies.

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MESH Headings

• Aged
• Aged, 80 and over
• Black People/statistics & numerical data
• Cohort Studies
• Community-Acquired Infections/ethnology
• Community-Acquired Infections/therapy
• Female
• Healthcare Disparities/statistics & numerical data
• Hospitals, Veterans
• Humans
• Intensive Care Units/statistics & numerical data
• Length of Stay/statistics & numerical data
• Male
• Pneumonia/ethnology
• Pneumonia/mortality
• Pneumonia/therapy
• Respiration, Artificial/statistics & numerical data
• Retrospective Studies
• United States/epidemiology
• Vasoconstrictor Agents/therapeutic use
• White People/statistics & numerical data
• Black or African American

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Grants

• UL1 TR000149 NCATS NIH HHS
• KL2 RR025766 NCRR NIH HHS
• R01NR010828 NINR NIH HHS
• KL2 TR000118 NCATS NIH HHS
• UL1 RR025767 NCRR NIH HHS

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Affiliation(s)

Christopher R Frei The University of Texas at Austin College of Pharmacy, 1 University Station, A1900, Austin, TX 78712, USA The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
Eric M Mortensen The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA South Texas Veterans Health Care System, Audie L. Murphy Division, 7400 Merton Minter Blvd, San Antonio, TX 78229, USA VERDICT Research Program, South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX 78229, USA
Laurel A Copeland The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA South Texas Veterans Health Care System, Audie L. Murphy Division, 7400 Merton Minter Blvd, San Antonio, TX 78229, USA VERDICT Research Program, South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX 78229, USA
Russell T Attridge The University of Texas at Austin College of Pharmacy, 1 University Station, A1900, Austin, TX 78712, USA The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
Mary Jo V Pugh The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA South Texas Veterans Health Care System, Audie L. Murphy Division, 7400 Merton Minter Blvd, San Antonio, TX 78229, USA VERDICT Research Program, South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX 78229, USA
Marcos I Restrepo The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA South Texas Veterans Health Care System, Audie L. Murphy Division, 7400 Merton Minter Blvd, San Antonio, TX 78229, USA VERDICT Research Program, South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX 78229, USA
Antonio Anzueto The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA South Texas Veterans Health Care System, Audie L. Murphy Division, 7400 Merton Minter Blvd, San Antonio, TX 78229, USA
Brandy Nakashima The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA South Texas Veterans Health Care System, Audie L. Murphy Division, 7400 Merton Minter Blvd, San Antonio, TX 78229, USA VERDICT Research Program, South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX 78229, USA
Michael J Fine Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, 7180 Highland Drive (151C-H), Pittsburgh, PA 15206, USA Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15213, USA

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