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Jackson I, Bley E. Racial/ethnic disparities in inpatient palliative care utilization and hospitalization outcomes among patients with colorectal cancer. Cancer Causes Control 2024; 35:711-717. [PMID: 38082093 DOI: 10.1007/s10552-023-01844-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 12/04/2023] [Indexed: 03/24/2024]
Abstract
PURPOSE Research has shown that racial/ethnic disparities exist in outcomes for colorectal cancer (CRC) patients, but there are no studies assessing inpatient palliative care utilization and hospitalization outcomes in this population. We examined racial/ethnic disparities in palliative care utilization and hospitalization outcomes among CRC and early-onset CRC patients. METHODS Using National Inpatient Sample (NIS) data collected between 2016 and 2018, cross-sectional analyses were performed. Descriptive analyses were done, stratified by race/ethnicity. Multivariable logistic and linear regression models were used to examine racial/ethnic differences in palliative care utilization, inpatient mortality, chemotherapy/radiotherapy use, length of stay and total hospital charges among hospitalized patients with CRC and early-onset CRC. RESULTS Blacks had higher odds (AOR: 1.09; 95% CI: 1.03-1.16) of receiving palliative care consultation while Hispanics had lower odds (AOR: 0.90; 95% CI: 0.84-0.96) compared to Whites. Blacks had 1.1 times higher odds (95% CI: 1.01-1.18) of inpatient mortality relative to Whites while Hispanics had 16% (AOR: 0.84; 95% CI: 0.76-0.93) lower odds of inpatient mortality. Compared to Whites, Blacks (AOR: 1.99; 95% CI: 1.64-2.41), Hispanics (AOR: 2.49; 95% CI: 1.94-3.19) and colorectal cancer patients in the other category (AOR: 1.72; 95% CI: 1.35-2.18) were more likely to receive inpatient treatment with chemotherapy/radiotherapy. Furthermore, Black patients were 1.1 times (95% CI: 1.06-1.14) more likely to have a length of stay more than 5 days. Blacks (𝛃: $3,096.7; 95% CI: $1,207.0-$4,986.5) Hispanic (𝛃: $10,237.5; 95% CI: $7,558.2-$12,916.8) and other patients (𝛃: $6,332.0; 95% CI: $2,830.9-$9, 833.2) had higher hospital charges relative to their White counterparts. Among patients with early onset CRC, Blacks had higher palliative care use (AOR: 1.29; 95% CI: 1.10-1.51) and inpatient mortality (AOR: 1.38; 95% CI: 1.06-1.79) while Hispanics reported $5,589.7 (95% CI: $683.2-$10,496.2) higher total hospital charges and were more likely to receive inpatient chemotherapy/radiotherapy (AOR: 2.48; 95% CI: 1.70-3.63). CONCLUSION Further research is needed to explore specific cultural, socioeconomic, and political factors that explain these disparities and identify ways to narrow the gap. Meanwhile, the healthcare sector will need to assess what strategies might be helpful in addressing these disparities in outcomes in the context of other socioeconomic and cultural factors that may be affecting the patients.
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Affiliation(s)
- Inimfon Jackson
- Department of Cancer Medicine, MD Anderson Cancer Center, Houston, TX, USA.
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA.
| | - Edward Bley
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
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Nwakasi CC, Esiaka D, Nweke C, de Medeiros K, Villamar W, Chidebe R. "We Don't Do Any of These Things Because We are a Death-Denying Culture": Sociocultural Perspectives of Black and Latinx Cancer Caregivers. RESEARCH SQUARE 2023:rs.3.rs-3470325. [PMID: 37961616 PMCID: PMC10635356 DOI: 10.21203/rs.3.rs-3470325/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
This qualitative study explored the unique challenges and experiences faced by Black and Latinx cancer survivors through the lens of their caregivers, including the specific cultural, social, and systemic factors that influence cancer survivorship experience within these communities in the United States. We conducted six focus group discussions (three Latinx and three Black groups) with a total of 33 caregivers of cancer survivors, (Mean age = 63 years). Data were analyzed using inductive content analysis; The sociocultural stress and coping model was used as a framework to interpret the findings. We identified three main themes: 1) families as (un)stressors in survivorship such as the vitality of social connections and families as unintended burden; 2) responses after diagnosis specifically whether to conceal or accept a diagnosis, and 3) experiencing health care barriers including communication gaps, biased prioritizing of care, and issues of power, trust, and need for stewardship. This study's findings align with previous research, highlighting the complex interplay between cultural, familial, and healthcare factors in cancer survivorship experiences within underserved communities. The study reiterates the need for culturally tailored emotional, physical, financial, and informational support for survivors and their caregivers. Also, the study highlights a need to strengthen mental health and coping strategies, to help address psychological distress and improve resilience among survivors and their caregivers.
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Islam Z, Pollock K, Patterson A, Hanjari M, Wallace L, Mururajani I, Conroy S, Faull C. Thinking ahead about medical treatments in advanced illness: a qualitative study of barriers and enablers in end-of-life care planning with patients and families from ethnically diverse backgrounds. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-135. [PMID: 37464868 DOI: 10.3310/jvfw4781] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Background This study explored whether or not, and how, terminally ill patients from ethnically diverse backgrounds and their family caregivers think ahead about deterioration and dying, and explored their engagement with health-care professionals in end-of-life care planning. Objective The aim was to address the question, what are the barriers to and enablers of ethnically diverse patients, family caregivers and health-care professionals engaging in end-of-life care planning? Design This was a qualitative study comprising 18 longitudinal patient-centred case studies, interviews with 19 bereaved family caregivers and 50 public and professional stakeholder responses to the findings. Setting The study was set in Nottinghamshire and Leicestershire in the UK. Results Key barriers - the predominant stance of patients was to live with hope, considering the future only in terms of practical matters (wills and funerals), rather than the business of dying. For some, planning ahead was counter to their faith. Health-care professionals seemed to feature little in people's lives. Some participants indicated a lack of trust and experienced a disjointed system, devoid of due regard for them. However, religious and cultural mores were of great importance to many, and there were anxieties about how the system valued and enabled these. Family duty and community expectations were foregrounded in some accounts and concern about being in the (un)care of strangers was common. Key enablers - effective communication with trusted individuals, which enables patients to feel known and that their faith, family and community life are valued. Health-care professionals getting to 'know' the person is key. Stakeholder responses highlighted the need for development of Health-care professionals' confidence, skills and training, Using stories based on the study findings was seen as an effective way to support this. A number of behavioural change techniques were also identified. Limitations It was attempted to include a broad ethnic diversity in the sample, but the authors acknowledge that not all groups could be included. Conclusions What constitutes good end-of-life care is influenced by the intersectionality of diverse factors, including beliefs and culture. All people desire personalised, compassionate and holistic end-of-life care, and the current frameworks for good palliative care support this. However, health-care professionals need additional skills to navigate complex, sensitive communication and enquire about aspects of people's lives that may be unfamiliar. The challenge for health-care professionals and services is the delivery of holistic care and the range of skills that are required to do this. Future work Priorities for future research: How can health professionals identify if/when a patient is 'ready' for discussions about deterioration and dying? How can discussions about uncertain recovery and the need for decisions about treatment, especially resuscitation, be most effectively conducted in a crisis? How can professionals recognise and respond to the diversity of faith and cultural practices, and the heterogeneity between individuals of beliefs and preferences relating to the end of life? How can conversations be most effectively conducted when translation is required to enhance patient understanding? Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. X. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Zoebia Islam
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Anne Patterson
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Matilda Hanjari
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Louise Wallace
- Faculty of Wellbeing, Education and Language Studies, The Open University, Milton Keynes, UK
| | - Irfhan Mururajani
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Simon Conroy
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Christina Faull
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
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Jackson I, Jackson N, Etuk A. Prevalence and Factors Associated with Palliative Care Utilization among Hospitalized Patients with Esophageal Cancer in the United States. J Palliat Care 2023; 38:192-199. [PMID: 35837723 DOI: 10.1177/08258597221113716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: Due to poor 5-year survival and high symptom burden, esophageal cancer (EC) patients benefit markedly from palliative care utilization. However, there is scant literature exploring factors associated with receipt of palliative care in this population. The prevalence of palliative care consultations among hospitalized EC patients was assessed. Furthermore, we examined the factors associated with palliative care utilization among hospitalized patients with EC. Methods: Retrospective analyses were conducted using the National Inpatient Sample data collected between 2016 and 2018. Descriptive analyses were used to explore the overall prevalence of palliative care utilization. Univariate and multivariable regression models were used to examine factors associated with palliative care utilization among hospitalized EC patients. Results: The overall prevalence of palliative care utilization was 15.97%. Non-Hispanic Blacks had 1.16 times (95% CI: 1.00-1.34) higher odds of palliative care utilization compared to non-Hispanic Whites. Compared to patients on Medicare, those on Medicaid (AOR: 1.21; 95% CI: 1.02-1.45), private (AOR: 1.19; 95% CI: 1.06-1.35) and other insurance types (AOR: 1.68; 95% CI: 1.39-2.02) were more likely to utilize palliative care. Relative to patients hospitalized in the Northeast, those in Midwest (AOR: 1.34; 95% CI: 1.17-1.53), south (AOR: 1.28; 95% CI: 1.12-1.45), and west (AOR: 1.41; 95% CI: 1.22-1.61) were more likely to receive palliative care. Patients admitted to urban teaching hospitals (AOR: 1.28; 95% CI: 1.07-1.52) had higher odds of having palliative care consultations when compared to their counterparts in rural hospitals. Also, patients who were either discharged to a facility/with home health (OR: 5.39; 95% CI: 4.76-6.10) or died during hospitalization (OR: 26.93; 95% CI: 23.31-31.11) had higher odds of utilizing palliative care when compared to those with a routine discharge. Other factors identified were median household income quartiles, admission type, chemotherapy receipt, and the number of comorbidities. Conclusions: Our findings highlight the need to further analyze and address factors that may hinder palliative care utilization among hospitalized EC patients to decrease disparities and improve their quality of life. Hospital physicians and health systems need to be more proactive about palliative care consultations to maximize the benefits to these sick cancer patients.
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Affiliation(s)
- Inimfon Jackson
- Department of Medicine, Einstein Medical Center, Philadelphia, USA
| | - Nsikak Jackson
- Department of Management, Policy and Community Health, University of Texas School of Public Health, 12340University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Aniekeme Etuk
- Department of Internal Medicine, Thomas Hospital Infirmary Health, Fairhope, Alabama, USA
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Barwise AK, Moriarty JP, Rosedahl JK, Soleimani J, Marquez A, Weister TJ, Gajic O, Borah BJ. Comparative costs for critically ill patients with limited English proficiency versus English proficiency. PLoS One 2023; 18:e0279126. [PMID: 37186248 PMCID: PMC10132690 DOI: 10.1371/journal.pone.0279126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 11/30/2022] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVES To conduct comparative cost analysis of hospital care for critically ill patients with Limited English Proficiency (LEP) versus patients with English proficiency (controls). PATIENTS AND METHODS We conducted a historical cohort study using propensity matching at Mayo Clinic Rochester, a quaternary care academic center. We included hospitalized patients who had at least one admission to ICU during a 10-year period between 1/1/2008-12/31/2017. RESULTS Due to substantial differences in baseline characteristics of the groups, propensity matching for the covariates age, sex, race, ethnicity, APACHE 3 score, and Charlson Comorbidity score was used, and we achieved the intended balance. The final cohort included 80,404 patients, 4,246 with LEP and 76,158 controls. Patients with LEP had higher costs during hospital admission to discharge, with a mean cost difference of $3861 (95% CI $822 to $6900, p = 0.013) and also higher costs during index ICU admission to hospital discharge, with a mean cost difference of $3166 (95% CI $231 to $6101, p = 0.035). A propensity matched cohort including only those that survived showed those with LEP had significantly greater mean costs for all outcomes. Sensitivity analysis revealed that international patients with LEP had significantly greater overall hospital costs of $9,240 than patients with LEP who resided in the US (95% CI $3341 to $15,140, p = 0.002). CONCLUSION This is the first study to demonstrate significantly higher costs for patients with LEP experiencing a critical illness. The causes for this may be increased healthcare utilization secondary to communication deficiencies that impede timely decision making about care.
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Affiliation(s)
- Amelia K Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- Bioethics Research Program, Mayo Clinic, Rochester, Minnesota, United States of America
| | - James P Moriarty
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Jordan K Rosedahl
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Jalal Soleimani
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Alberto Marquez
- Anesthesia Clinical Research Unit (ACRU), Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Timothy J Weister
- Anesthesia Clinical Research Unit (ACRU), Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Bijan J Borah
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, United States of America
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Callinan K, Grube D, Ramirez V. Medical Aid in Dying. Cancer Treat Res 2023; 187:347-360. [PMID: 37851240 DOI: 10.1007/978-3-031-29923-0_26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
As the nation's 75 million baby boomers enter into a new phase of their life, care for their aging parents, and contemplate their own mortality, many have come to realize that our end-of-life care system is hamstrung by outdated modes of dying. This chapter discusses the current status of medical aid in dying in the United States as a legal and medically recognized medical option for supporting patients at life's end.
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Affiliation(s)
- Kim Callinan
- Compassion and Choices, Portland, Oregon, United States.
| | - David Grube
- Compassion and Choices, Portland, Oregon, United States
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Shore S, O'Leary M, Kamdar N, Harrod M, Silveira MJ, Hummel SL, Nallamothu BK. Do Not Attempt Resuscitation Order Rates in Hospitalized Patients With Heart Failure, Acute Myocardial Infarction, Chronic Obstructive Pulmonary Disease, and Pneumonia. J Am Heart Assoc 2022; 11:e025730. [PMID: 36382963 PMCID: PMC9851455 DOI: 10.1161/jaha.122.025730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Descriptions of do not attempt resuscitation (DNAR) orders in heart failure (HF) are limited. We describe use of DNAR orders in HF hospitalizations relative to other common conditions, focusing on race. Methods and Results This was a retrospective study of all adult hospitalizations for HF, acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), and pneumonia from 2010 to 2016 using the California State Inpatient Dataset. Using a hierarchical multivariable logistic regression model with random effects for the hospital, we identified factors associated with DNAR orders for each condition. For racial variation, hospitals were divided into quintiles based on proportion of Black patients cared for. Our cohort comprised 399 816 HF, 190 802 AMI, 192 640 COPD, and 269 262 pneumonia hospitalizations. DNAR orders were most prevalent in HF (11.9%), followed by pneumonia (11.1%), COPD (7.9%), and AMI (7.1%). Prevalence of DNAR orders did not change from 2010 to 2016 for each condition. For all conditions, DNAR orders were more common in elderly people, women, and White people with significant site-level variation across 472 hospitals. For HF and COPD, hospitalizations at sites that cared for a higher proportion of Black patients were less likely associated with DNAR orders. For AMI and pneumonia, conditions such as dementia and malignancy were strongly associated with DNAR orders. Conclusions DNAR orders were present in 12% of HF hospitalizations, similar to pneumonia but higher than AMI and COPD. For HF, we noted significant variability across sites when stratified by proportion of Black patients cared for, suggesting geographic and racial differences in end-of-life care.
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Affiliation(s)
- Supriya Shore
- Division of Internal MedicineUniversity of MichiganAnn ArborMI,Institute of Healthcare Policy and Innovation, University of MichiganAnn ArborMI
| | - Michael O'Leary
- Division of Internal MedicineUniversity of MichiganAnn ArborMI,Institute of Healthcare Policy and Innovation, University of MichiganAnn ArborMI
| | - Neil Kamdar
- Division of Internal MedicineUniversity of MichiganAnn ArborMI,Institute of Healthcare Policy and Innovation, University of MichiganAnn ArborMI
| | - Molly Harrod
- Veterans Affairs Ann Arbor Center for Clinical Management ResearchAnn ArborMI
| | - Maria J. Silveira
- Division of Internal MedicineUniversity of MichiganAnn ArborMI,Veterans Affairs Geriatric Research Education and Clinical CenterAnn ArborMI
| | - Scott L. Hummel
- Division of Internal MedicineUniversity of MichiganAnn ArborMI,Institute of Healthcare Policy and Innovation, University of MichiganAnn ArborMI,Veterans Affairs Ann Arbor Center for Clinical Management ResearchAnn ArborMI
| | - Brahmajee K. Nallamothu
- Division of Internal MedicineUniversity of MichiganAnn ArborMI,Institute of Healthcare Policy and Innovation, University of MichiganAnn ArborMI,Veterans Affairs Ann Arbor Center for Clinical Management ResearchAnn ArborMI
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Makris D, Tsolaki V, Robertson R, Dimopoulos G, Rello J. The future of training in intensive care medicine: A European perspective. JOURNAL OF INTENSIVE MEDICINE 2022; 3:52-61. [PMID: 36789360 PMCID: PMC9923960 DOI: 10.1016/j.jointm.2022.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/12/2022] [Accepted: 07/12/2022] [Indexed: 01/19/2023]
Affiliation(s)
| | | | - Ross Robertson
- Medical School, University of Thessaly, Larisa 41110, Greece
| | - George Dimopoulos
- Third Department of Critical Care, Medical School, National and Kapodistrian University of Athens, Athens 12462, Greece
| | - Jordi Rello
- CRIPS Department, Vall d'Hebron Institut of Research, Barcelona 08035, Spain,Clinical Research, CHU Nîmes, Nîmes 30029, France,Medical School, Universitat Internacional de Catalunya, Campus Sant Cugat, Sant Cugat del Valles, Barcelona 08195, Spain,Corresponding author: Jordi Rello, CRIPS Department, Vall d'Hebron Institut of Research, Barcelona 08035, Spain.
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9
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Luth EA, Manful A, Prigerson HG, Xiang L, Reich A, Semco R, Weissman JS. Associations between dementia diagnosis and end-of-life care utilization. J Am Geriatr Soc 2022; 70:2871-2883. [PMID: 35822659 PMCID: PMC9588556 DOI: 10.1111/jgs.17952] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 05/27/2022] [Accepted: 06/09/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND Dementia is a leading cause of death for older adults and is more common among persons from racial/ethnic minoritized groups, who also tend to experience more intensive end-of-life care. This retrospective cohort study compared end-of-life care in persons with and without dementia and identified dementia's moderating effects on the relationship between race/ethnicity and end-of-life care. METHODS Administrative claims data for 463,590 Medicare fee-for-service decedents from 2016 to 2018 were analyzed. Multivariable logistic and linear regression analyses examined the association of dementia with 5 intensive and 2 quality of life-focused measures. Intensity measures included hospital admission, ICU admission, receipt of any of 5 intensive procedures (CPR, mechanical ventilation, intubation, dialysis initiation, and feeding tube insertion), hospital death, and Medicare expenditures (last 30 days of life). Quality of life measures included timely hospice care (>3 days before death) and days at home (last 6 months of life). Models were adjusted for demographic and clinical factors. RESULTS 54% of Medicare decedents were female, 85% non-Hispanic White, 8% non-Hispanic Black, and 4% Hispanic. Overall, 51% had a dementia diagnosis claim. In adjusted models, decedents with dementia had 16%-29% lower odds of receiving intensive services (AOR hospital death: 0.71, 95% CI: 0.70-0.72; AOR hospital admission: 0.84, 95% CI: 0.83-0.86). Patients with dementia had 45% higher odds of receiving timely hospice (AOR: 1.45, 95% CI: 1.42-1.47), but spent 0.74 fewer days at home (adjusted mean: -0.74, 95% CI: (-0.98)-(-0.49)). Compared to non-Hispanic White individuals, persons from racial/ethnic minoritized groups were more likely to receive intensive services. This effect was more pronounced among persons with dementia. CONCLUSIONS Although overall dementia was associated with fewer intensive services near death, beneficiaries from racial/ethnic groups minoritized with dementia experienced more intensive service use. Particular attention is needed to ensure care aligns with the needs and preferences of persons with dementia and from racial/ethnic minoritized groups.
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Affiliation(s)
- Elizabeth A. Luth
- Institute for Health, Healthcare Policy and Aging Research, Department of Family Medicine and Community HealthRutgers UniversityNew BrunswickNew JerseyUSA
| | - Adoma Manful
- School of Medicine, Division of EpidemiologyVanderbilt UniversityNashvilleUSA
| | - Holly G. Prigerson
- Department of Geriatrics and Palliative MedicineWeill Cornell MedicineNew York CityNew YorkUSA
| | - Lingwei Xiang
- Center for Surgery and Public Health, Brigham and Women's HospitalHarvard UniversityCambridgeMassachusettsUSA
| | - Amanda Reich
- Center for Surgery and Public Health, Brigham and Women's HospitalHarvard UniversityCambridgeMassachusettsUSA
| | | | - Joel S. Weissman
- Center for Surgery and Public Health, Brigham and Women's HospitalHarvard UniversityCambridgeMassachusettsUSA
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Moin EE, Okin D, Jesudasen SJ, Dandawate NA, Gavralidis A, Chang LL, Witkin AS, Hibbert KA, Kadar A, Gordan PL, Bebell LM, Lai PS, Alba GA. Code status orders in patients admitted to the intensive care unit with COVID-19: a retrospective cohort study. Resusc Plus 2022; 10:100219. [PMID: 35284847 PMCID: PMC8898738 DOI: 10.1016/j.resplu.2022.100219] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/25/2022] [Accepted: 02/28/2022] [Indexed: 12/12/2022] Open
Abstract
Purpose Materials and methods Results Conclusions
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Affiliation(s)
- Emily E. Moin
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel Okin
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | | | | | - Leslie L. Chang
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Alison S. Witkin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kathryn A. Hibbert
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Aran Kadar
- Division of Pulmonary Medicine and Critical Care, Newton-Wellesley Hospital, Newton, MA, USA
| | - Patrick L. Gordan
- Department of Medicine, Salem Hospital, Salem, MA, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, Salem Hospital, Salem, MA, USA
| | - Lisa M. Bebell
- Division of Infectious Diseases, Medical Practice Evaluation Center and Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
| | - Peggy S. Lai
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - George A. Alba
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
- Corresponding author at: 55 Fruit Street, Bulfinch 148, Boston, MA 02114, USA.
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11
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George LS, Polacek LC, Lynch K, Prigerson HG, Abou-Alfa GK, Atkinson TM, Epstein AS, Breitbart W. Reconciling the prospect of disease progression with goals and expectations: Development and validation of a measurement model in advanced cancer. Psychooncology 2022; 31:902-910. [PMID: 34984756 DOI: 10.1002/pon.5878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 12/08/2021] [Accepted: 12/15/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Among patients living with advanced, life-limiting illness, reconciling the prospect of disease progression with future goals and expectations is a key psychological task, integral to treatment decision-making and emotional well-being. To date, this psychological process remains poorly understood with no available measurement tools. The present paper develops and validates a measurement model for operationalizing this psychological process. METHODS In Phase 1, concept elicitation interviews were conducted among Stage IV lung, gastrointestinal, and gynecologic cancer patients, their caregivers, and experts (N = 19), to further develop our conceptual framework centered on assimilation and accommodation coping. In Phase 2, draft self-report items of common assimilation and accommodation coping strategies were evaluated via patient cognitive interviews (N = 11). RESULTS Phase 1 interviews identified several coping strategies, some of which aimed to reduce the perceived likelihood of disease progression (assimilation), and others aimed to integrate the likelihood into new goals and expectations (accommodation). The coping strategies appeared to manifest in patients' daily lives, and integrally related to their emotional well-being and how they think about treatments. Phase 2 cognitive interviews identified items to remove and modify, resulting in a 31-item measure assessing 10 assimilation and accommodation coping strategies. CONCLUSIONS The present work derived a content-valid measure of the psychological process by which patients reconcile the prospect of disease progression with their goals and expectations. Further psychometric validation and use of the scale could identify intervention targets for enhancing patient decision-making and well-being.
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Affiliation(s)
- Login S George
- Institute for Health, Rutgers University, New Brunswick, New Jersey, USA
| | - Laura C Polacek
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Psychology, Fordham University, New York, New York, USA
| | - Kathleen Lynch
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Holly G Prigerson
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Ghassan K Abou-Alfa
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Thomas M Atkinson
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andrew S Epstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - William Breitbart
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Evaluating the Contribution of Patient-Provider Communication and Cancer Diagnosis to Racial Disparities in End-of-Life Care Among Medicare Beneficiaries. J Gen Intern Med 2021; 36:3311-3320. [PMID: 33963508 PMCID: PMC8606371 DOI: 10.1007/s11606-021-06778-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The quality of end-of-life (EOL) care in the USA remains suboptimal, with significant variations in care by race and across disease subgroups. Patient-provider communication may contribute to racial and disease-specific variations in EOL care outcomes. OBJECTIVE We examined racial disparities in EOL care, by disease group (cancer vs. non-cancer), and assessed whether racial differences in patient-provider communication accounted for observed disparities. DESIGN Retrospective cohort study using the 2001-2015 Surveillance, Epidemiology, and End Results - Consumer Assessment of Healthcare Providers and Systems data linked with Medicare claims (SEER-CAHPS). We employed stratified propensity score matching and modified Poisson regression analyses, adjusting for clinical and demographic characteristics PARTICIPANTS: Black and White Medicare beneficiaries 65 years or older with cancer (N=2000) or without cancer (N=11,524). MAIN MEASURES End-of-life care measures included hospice use, inpatient hospitalizations, intensive care unit (ICU) stays, and emergency department (ED) visits, during the 90 days prior to death. KEY RESULTS When considering all conditions together (cancer + non-cancer), Black beneficiaries were 26% less likely than their Whites counterparts to enroll in hospice (adjusted risk ratio [ARR]: 0.74, 95%CI: 0.66-0.83). Among beneficiaries without cancer, Black beneficiaries had a 32% lower likelihood of enrolling in hospice (ARR: 0.68, 95%CI: 0.59-0.79). There was no racial difference in hospice enrollment among cancer patients. Black beneficiaries were also at increased risk for ED use (ARR: 1.12, 95%CI: 1.01-1.26). Patient-provider communication did not explain racial disparities in hospice or ED use. There were no racial differences in hospitalizations or ICU admissions. CONCLUSION We observed racial disparities in hospice use and ED visits in the 90 days prior to death among Medicare beneficiaries; however, hospice disparities were largely driven by patients without cancer. Condition-specific differences in palliative care integration at the end-of-life may partly account for variations in EOL care disparities across disease groups.
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Patel MI, Khateeb S, Coker T. Association of a Lay Health Worker-Led Intervention on Goals of Care, Quality of Life, and Clinical Trial Participation Among Low-Income and Minority Adults With Cancer. JCO Oncol Pract 2021; 17:e1753-e1762. [PMID: 33999691 PMCID: PMC9810146 DOI: 10.1200/op.21.00100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE New approaches are needed to overcome low supportive care and clinical trial participation among low-income and minority adults with cancer. The objective of this project was to determine whether a lay health worker intervention was associated with improvements in supportive care and trial participation. METHODS We conducted a quality improvement initiative in collaboration with a union organization. We enrolled union members newly diagnosed with cancer into a 6-month lay health worker-led intervention from October 15, 2016, to February 28, 2017. The primary outcome was goals of care. Secondary outcomes were health-related quality of life (HRQOL), health care use, and trial participation. All outcomes except HRQOL were compared with a cohort of union members diagnosed within the 6-month preintervention period. RESULTS Sixty-six adults participated in the intervention group, and we identified 72 adults in the control group. Demographic characteristics were similar between groups. The mean age was 56.0 years; 47 (34%) were male, and 22 were White (16%). Within 6 months enrollment, more intervention group participants, as compared with the control, had clinician-documented goals of care (94% v 26%; P < .001) and participated in cancer clinical trials (72% v 22%; P < .001). At 4 months postenrollment, as compared with baseline, intervention participants experienced HRQOL improvements (mean difference, 3.98 points; standard deviation, 2.83; P < .001). Before death, more intervention group participants used palliative care and hospice than the control group. CONCLUSION Lay health worker-led interventions may improve supportive care and clinical trial participation among low-income and minority populations with cancer.
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Affiliation(s)
- Manali I Patel
- Division of Oncology, Stanford University School of Medicine, Stanford, CA.,Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.,Center for Primary Care and Outcomes Research/Health Research and Policy, Stanford University School of Medicine, Stanford, CA
| | - Sana Khateeb
- Division of Oncology, Stanford University School of Medicine, Stanford, CA
| | - Tumaini Coker
- Seattle Children's Research Institute, Seattle, WA.,Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
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Abstract
OBJECTIVES Racial disparities in the United States healthcare system are well described across a variety of clinical settings. The ICU is a clinical environment with a higher acuity and mortality rate, potentially compounding the impact of disparities on patients. We sought to systematically analyze the literature to assess the prevalence of racial disparities in the ICU. DATA SOURCES We conducted a comprehensive search of PubMed/MEDLINE, Scopus, CINAHL, and the Cochrane Library. STUDY SELECTION We identified articles that evaluated racial differences on outcomes among ICU patients in the United States. Two authors independently screened and selected articles for inclusion. DATA EXTRACTION We dual-extracted study characteristics and outcomes that assessed for disparities in care (e.g., in-hospital mortality, ICU length of stay). Studies were assessed for bias using the Newcastle-Ottawa Scale. DATA SYNTHESIS Of 1,325 articles screened, 25 articles were included (n = 751,796 patients). Studies demonstrated race-based differences in outcomes, including higher mortality rates for Black patients when compared with White patients. However, when controlling for confounding variables, such as severity of illness and hospital type, mortality differences based on race were no longer observed. Additionally, results revealed that Black patients experienced greater financial impacts during an ICU admission, were less likely to receive early tracheostomy, and were less likely to receive timely antibiotics than White patients. Many studies also observed differences in patients' end-of-life care, including lower rates on the quality of dying, less advanced care planning, and higher intensity of interventions at the end of life for Black patients. CONCLUSIONS This systematic review found significant differences in the care and outcomes among ICU patients of different races. Mortality differences were largely explained by accompanying demographic and patient factors, highlighting the effect of structural inequalities on racial differences in mortality in the ICU. This systematic review provides evidence that structural inequalities in care persist in the ICU, which contribute to racial disparities in care. Future research should evaluate interventions to address inequality in the ICU.
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Boyce-Fappiano D, Liao K, Miller C, Peterson SK, Elting L, Guadagnolo BA. Preferences for More Aggressive End-of-life Pharmacologic Care Among Racial Minorities in a Large Population-Based Cohort of Cancer Patients. J Pain Symptom Manage 2021; 62:482-491. [PMID: 33556498 PMCID: PMC8339155 DOI: 10.1016/j.jpainsymman.2021.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/26/2021] [Accepted: 02/01/2021] [Indexed: 11/21/2022]
Abstract
CONTEXT Minority patients receive more aggressive and potentially suboptimal care at the end of life (EOL). We investigated preferences about pharmacologic interventions at the EOL and their potential variation by sociodemographic factors among recently diagnosed cancer patients. METHODS A population-based cross-sectional survey of cancer patients identified through the Texas Cancer registry was conducted using a multi-scale inventory between March 2018 and June 2020. Item responses to questions about potential pharmacologic interventions at the EOL were the focus of this investigation. Inverse probability weighted multivariate analysis examined associations of sociodemographic characteristics, health literacy, and trust in medical professionals with pharmacologic preferences. RESULTS Of the 1480 included responses, 13.3% stated they would take a medication that may prolong life at the cost of feeling worse. Adjusted analyses showed Black or Hispanic race/ethnicity, living with another person, and having a higher trust score were more likely to express this preference. In contrast, 41-65 years (vs. 21-40 years), living in a rural area, and adequate or unknown health literacy were less likely to express this preference. Overall 16% of respondents were opposed to potentially life shortening palliative drugs. In adjusted analysis Black or Hispanic respondents were more likely to be opposed to potentially life shortening drugs although age 65-79 and ≥college education were associated with a decreased likelihood of opposition to this item. CONCLUSION Black and Hispanic cancer patients were more likely to express preferences toward more aggressive EOL pharmacologic care. These findings were independent of other sociodemographic characteristics, health literacy and trust in the medical profession.
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Affiliation(s)
| | - Kaiping Liao
- Department of Health Services Research, MD Anderson Cancer Center, Houston, Texas
| | - Christopher Miller
- Department of Behavioral Science, MD Anderson Cancer Center, Houston, Texas
| | - Susan K Peterson
- Department of Behavioral Science, MD Anderson Cancer Center, Houston, Texas
| | - Linda Elting
- Department of Health Services Research, MD Anderson Cancer Center, Houston, Texas
| | - B Ashleigh Guadagnolo
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas; Department of Health Services Research, MD Anderson Cancer Center, Houston, Texas.
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Miller DR, Berger JT. Ethics and Society: Physician Assisted Suicide and White Ethnocentrism. J Pain Symptom Manage 2021; 62:e1-e2. [PMID: 34077787 DOI: 10.1016/j.jpainsymman.2021.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 05/17/2021] [Accepted: 05/26/2021] [Indexed: 12/01/2022]
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Barwise A, Wi CI, Frank R, Milekic B, Andrijasevic N, Veerabattini N, Singh S, Wilson ME, Gajic O, Juhn YJ. An Innovative Individual-Level Socioeconomic Measure Predicts Critical Care Outcomes in Older Adults: A Population-Based Study. J Intensive Care Med 2021; 36:828-837. [PMID: 32583721 PMCID: PMC7759584 DOI: 10.1177/0885066620931020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little is known about the impact of socioeconomic status (SES) as a key element of social determinants of health on intensive care unit (ICU) outcomes for adults. OBJECTIVE We assessed whether a validated individual SES index termed HOUSES (HOUsing-based SocioEconomic status index) derived from housing features was associated with short-term outcomes of critical illness including ICU mortality, ICU-free days, hospital-free days, and ICU readmission. METHODS We performed a population-based cohort study of adult patients living in Olmsted County, Minnesota, admitted to 7 intensive care units at Mayo Clinic from 2011 to 2014. We compared outcomes between the lowest SES group (HOUSES quartile 1 [Q1]) and the higher SES group (HOUSES Q2-4). We stratified the cohort based on age (<50 years old and ≥50 years old). RESULTS Among 4134 eligible patients, 3378 (82%) patients had SES successfully measured by the HOUSES index. Baseline characteristics, severity of illness, and reason for ICU admission were similar among the different SES groups as measured by HOUSES except for larger number of intoxications and overdoses in younger patients from the lowest SES. In all adult patients, there were no overall differences in mortality, ICU-free days, hospital-free days, or ICU readmissions in patients with higher SES compared to lower SES. Among older patients (>50 years), those with higher SES (HOUSES Q2-4) compared to those with lower SES (HOUSES Q1) had lower mortality rates (hazard ratio = 0.72; 95% CI: 0.56-0.93; adjusted P = .01), increased ICU-free days (mean 1.08 days; 95% CI: 0.34-1.84; adjusted P = .004), and increased hospital-free days (mean 1.20 days; 95% CI: 0.45-1.96; adjusted P = .002). There were no differences in ICU readmission rates (OR = 0.74; 95% CI: 0.55-1.00; P = .051). CONCLUSION Individual-level SES may be an important determinant or predictor of critical care outcomes in older adults. Housing-based socioeconomic status may be a useful tool for enhancing critical care research and practice.
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Affiliation(s)
- Amelia Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Chung-Il Wi
- Precision Population Science lab and Department of Pediatric and Adolescent Medicine and Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ryan Frank
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Bojana Milekic
- Department of Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania
| | - Nicole Andrijasevic
- Anesthesia Clinical Research Unit(ACRU), Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Naresh Veerabattini
- Department of Internal Medicine, University of Nevada Reno School of Medicine, Reno, Nevada
| | - Sidhant Singh
- Department of Internal Medicine, Yale Waterbury Internal Medicine Residency, Waterbury, Connecticut
| | - Michael E. Wilson
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Young J. Juhn
- Precision Population Science lab and Department of Pediatric and Adolescent Medicine and Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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Brenner AB, Skolarus LE, Perumalswami CR, Burke JF. Understanding End-of-Life Preferences: Predicting Life-Prolonging Treatment Preferences Among Community-Dwelling Older Americans. J Pain Symptom Manage 2020; 60:595-601.e3. [PMID: 32376264 PMCID: PMC7483277 DOI: 10.1016/j.jpainsymman.2020.04.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/03/2020] [Accepted: 04/05/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To determine how demographic, socioeconomic, health, and psychosocial factors predict preferences to accept life-prolonging treatments (LPTs) at the end of life (EOL). METHODS This is a retrospective cohort study of a nationally representative sample of community-dwelling older Americans (N = 1648). Acceptance of LPT was defined as wanting to receive all LPTs in the hypothetical event of severe disability or severe chronic pain at the EOL. Participants with a durable power of attorney, living will, or who discussed EOL with family were determined to have expressed their EOL preferences. The primary analysis used survey-weighted logistic regression to measure the association between older adult characteristics and acceptance of LPT. Secondarily, the associations between LPT preferences and health outcomes were measured using regression models. RESULTS Approximately 31% of older adults would accept LPT. Nonwhite race/ethnicity (odds ratio [OR] 0.54; 95% CI 0.41, 0.70; white vs. nonwhite), self-realization (OR 1.34; 95% CI 1.01, 1.79), attendance of religious services (OR 1.44; 95% CI 1.07, 1.94), and expression of preferences (OR 0.54; 95% CI 0.40, 0.72) were associated with acceptance of LPT. LPT preferences were not independently associated with mortality or disability. CONCLUSIONS Approximately one-third of older Americans would accept LPT in the setting of severe disability or severe chronic pain at the EOL. Adults who discussed their EOL preferences were more likely to reject LPT. Conversely, minorities were more likely to accept LPT. Sociodemographics, physical capacity, and health status were poor predictors of acceptance of LPT. A better understanding of the complexities of LPT preferences is important to ensuring patient-centered care.
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Affiliation(s)
- Allison B Brenner
- Survey Research Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Lesli E Skolarus
- Population Health Research Director, Cascadia Behavioral Healthcare, Portland, Oregon, USA; Department of Neurology, Stroke Program, Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Chithra R Perumalswami
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - James F Burke
- Department of Neurology, Stroke Program, Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, Michigan, USA.
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Ornstein KA, Roth DL, Huang J, Levitan EB, Rhodes JD, Fabius CD, Safford MM, Sheehan OC. Evaluation of Racial Disparities in Hospice Use and End-of-Life Treatment Intensity in the REGARDS Cohort. JAMA Netw Open 2020; 3:e2014639. [PMID: 32833020 PMCID: PMC7445597 DOI: 10.1001/jamanetworkopen.2020.14639] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/12/2020] [Indexed: 01/08/2023] Open
Abstract
Importance Although hospice use is increasing and patients in the US are increasingly dying at home, racial disparities in treatment intensity at the end of life, including hospice use, remain. Objective To examine differences between Black and White patients in end-of-life care in a population sample with well-characterized causes of death. Design, Setting, and Participants This study used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, an ongoing population-based cohort study with enrollment between January 25, 2003, and October 3, 2007, with linkage to Medicare claims data. Multivariable logistic regression models were used to examine racial and regional differences in end-of-life outcomes and in stroke mortality among 1212 participants with fee-for-service Medicare who died between January 1, 2013, and December 31, 2015, owing to natural causes and excluding sudden death, with oversampling of Black individuals and residents of Southeastern states in the United States. Initial analyses were conducted in March 2019, and final primary analyses were conducted in February 2020. Main Outcomes and Measures The primary outcomes of interest were hospice use of 3 or more days in the last 6 months of life derived from Medicare claims files. Other outcomes included multiple hospitalizations, emergency department visits, and use of intensive procedures in the last 6 months of life. Cause of death was adjudicated by an expert panel of clinicians using death certificates, proxy interviews, autopsy reports, and medical records. Results The sample consisted of 1212 participants (630 men [52.0%]; 378 Black individuals [31.2%]; mean [SD] age at death, 81.0 [8.6] years) of 2542 total deaths. Black decedents were less likely than White decedents to use hospice for 3 or more days (132 of 378 [34.9%] vs 385 of 834 [46.2%]; P < .001). After stratification by cause of death, substantial racial differences in treatment intensity and service use were found among persons who died of cardiovascular disease but not among patients who died of cancer. In analyses adjusted for cause of death (dementia, cancer, cardiovascular disease, and other) and clinical and demographic variables, Black decedents were significantly less likely to use 3 or more days of hospice (odds ratio [OR], 0.72; 95% CI, 0.54-0.96) and were more likely to have multiple emergency department visits (OR, 1.35; 95% CI, 1.01-1.80) and hospitalizations (OR, 1.39; 95% CI, 1.02-1.89) and undergo intensive treatment (OR, 1.94; 95% CI, 1.40-2.70) in the last 6 months of life compared with White decedents. Conclusions and Relevance Despite the increase in the use of hospice care in recent decades, racial disparities in the use of hospice remain, especially for noncancer deaths. More research is required to better understand racial disparities in access to and quality of end-of-life care.
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Affiliation(s)
- Katherine A. Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - David L. Roth
- Center on Aging and Health, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jin Huang
- Center on Aging and Health, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Emily B. Levitan
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham
| | - J. David Rhodes
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham
| | - Chanee D. Fabius
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Monika M. Safford
- Division of General Internal Medicine, Weill Cornell Medicine, New York, New York
| | - Orla C. Sheehan
- Center on Aging and Health, Johns Hopkins School of Medicine, Baltimore, Maryland
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Patel M, Andrea N, Jay B, Coker TR. A Community-Partnered, Evidence-Based Approach to Improving Cancer Care Delivery for Low-Income and Minority Patients with Cancer. J Community Health 2020; 44:912-920. [PMID: 30825097 DOI: 10.1007/s10900-019-00632-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Community-engaged adaptations of evidence-based interventions are needed to improve cancer care delivery for low-income and minority populations with cancer. The objective of this study was to adapt an intervention to improve end-of-life cancer care delivery using a community-partnered approach. We used a two-step formative research process to adapt the evidence-based lay health workers educate engage and encourage patients to share (LEAPS) cancer care intervention. The first step involved obtaining a series of adaptations through focus groups with 15 patients, 12 caregivers, and 6 leaders and staff of the Unite Here Health (UHH) payer organization, and 12 primary care and oncology care providers. Focus group discussions were recorded, transcribed, and analyzed using the constant comparative method of qualitative analysis. The second step involved finalization of adaptations from a community advisory board comprised of 4 patients, 2 caregivers, 4 oncology providers, 2 lay health workers and 4 UHH healthcare payer staff and executive leaders. Using this community-engaged approach, stakeholders identified critical barriers and solutions to intervention delivery which included: (1) expanding the intervention to ensure patient recruitment; (2) including caregivers; (3) regular communication between UHH staff, primary care and oncology providers; and (4) selecting outcomes that reflect patient-reported quality of life. This systematic and community-partnered approach to adapt an end-of-life cancer care intervention strengthened this existing intervention to promote the needs and preferences of patients, caregivers, providers, and healthcare payer leaders. This approach can be used to address cancer care delivery for low-income and minority patients with cancer.
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Affiliation(s)
- Manali Patel
- Division of Oncology, Stanford University School of Medicine, 1070 Arastradero, Palo Alto, CA, 94305, USA.
- Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA, USA.
| | - Nevedal Andrea
- Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Bhattacharya Jay
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA, USA
| | - Tumaini R Coker
- Seattle Children's Research Institute, Seattle, WA, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
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Johnson LSM. Restoring Trust and Requiring Consent in Death by Neurological Criteria. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:33-35. [PMID: 32618506 DOI: 10.1080/15265161.2020.1754508] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
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Tramontano AC, Chen Y, Watson TR, Eckel A, Hur C, Kong CY. Racial/ethnic disparities in colorectal cancer treatment utilization and phase-specific costs, 2000-2014. PLoS One 2020; 15:e0231599. [PMID: 32287320 PMCID: PMC7156060 DOI: 10.1371/journal.pone.0231599] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 03/26/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Our study analyzed disparities in utilization and phase-specific costs of care among older colorectal cancer patients in the United States. We also estimated the phase-specific costs by cancer type, stage at diagnosis, and treatment modality. METHODS We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify patients aged 66 or older diagnosed with colon or rectal cancer between 2000-2013, with follow-up to death or December 31, 2014. We divided the patient's experience into separate phases of care: staging or surgery, initial, continuing, and terminal. We calculated total, cancer-attributable, and patient-liability costs. We fit logistic regression models to determine predictors of treatment receipt and fit linear regression models to determine relative costs. All costs are reported in 2019 US dollars. RESULTS Our cohort included 90,023 colon cancer patients and 25,581 rectal cancer patients. After controlling for patient and clinical characteristics, Non-Hispanic Blacks were less likely to receive treatment but were more likely to have higher cancer-attributable costs within different phases of care. Overall, in both the colon and rectal cancer cohorts, mean monthly cost estimates were highest in the terminal phase, next highest in the staging phase, decreased in the initial phase, and were lowest in the continuing phase. CONCLUSIONS Racial/ethnic disparities in treatment utilization and costs persist among colorectal cancer patients. Additionally, colorectal cancer costs are substantial and vary widely among stages and treatment modalities. This study provides information regarding cost and treatment disparities that can be used to guide clinical interventions and future resource allocation to reduce colorectal cancer burden.
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Affiliation(s)
- Angela C. Tramontano
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Yufan Chen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Tina R. Watson
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Andrew Eckel
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Chin Hur
- Columbia University Medical Center, New York City, New York, United States of America
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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Patel MI, Khateeb S, Coker T. A randomized trial of a multi-level intervention to improve advance care planning and symptom management among low-income and minority employees diagnosed with cancer in outpatient community settings. Contemp Clin Trials 2020; 91:105971. [PMID: 32145441 DOI: 10.1016/j.cct.2020.105971] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 02/20/2020] [Accepted: 02/28/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Equitable delivery of advance care planning and symptom management among patients is crucial to improving cancer care. Existing interventions to improve the uptake of these services have predominantly occurred in clinic settings and are limited in their effectiveness, particularly among low-income and minority populations. METHODS The "Lay health worker Educates Engages and Activates Patients to Share (LEAPS)" intervention was developed to improve advance care planning and symptom management among low-income and minority hourly-wage workers with cancer, in two community settings. The intervention provides a lay health worker to all patients newly diagnosed with cancer and aims to educate and activate patients to engage in advance care planning and symptom management with their oncology providers. In this randomized clinical trial, we will evaluate the effect on quality of life (primary outcome) using the validated Functional Assessment of Cancer Therapy - General Survey, at enrollment, 4- and 12- months post-enrollment. We will examine between-group differences on our secondary outcomes of patient activation, patient satisfaction with healthcare decision-making, and symptom burden (at enrollment, 4- and 12-months post-enrollment), and total healthcare use and healthcare costs (at 12-months post-enrollment). DISCUSSION Multilevel approaches are urgently needed to improve cancer care delivery among low-income and minority patients diagnosed with cancer in community settings. The current study describes the LEAPS intervention, the study design, and baseline characteristics of the community centers participating in the study. ClinicalTrials.gov Registration #NCT03699748.
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Affiliation(s)
- Manali I Patel
- Division of Oncology, Stanford University School of Medicine, Stanford, CA, United States of America; Medical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States of America; Center for Primary Care and Outcomes Research/Health Research and Policy, Stanford University School of Medicine, Stanford, CA, United States of America.
| | - Sana Khateeb
- Division of Oncology, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Tumaini Coker
- Seattle Children's Research Institute, Seattle, WA, United States of America; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States of America
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Chen Y, Criss SD, Watson TR, Eckel A, Palazzo L, Tramontano AC, Wang Y, Mercaldo ND, Kong CY. Cost and Utilization of Lung Cancer End-of-Life Care Among Racial-Ethnic Minority Groups in the United States. Oncologist 2020; 25:e120-e129. [PMID: 31501272 PMCID: PMC6964141 DOI: 10.1634/theoncologist.2019-0303] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/06/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The end-of-life period is a crucial time in lung cancer care. To have a better understanding of the racial-ethnic disparities in health care expenditures, access, and quality, we evaluated these disparities specifically in the end-of-life period for patients with lung cancer in the U.S. MATERIALS AND METHODS We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to analyze characteristics of lung cancer care among those diagnosed between the years 2000 and 2011. Linear and logistic regression models were constructed to measure racial-ethnic disparities in end-of-life care cost and utilization among non-Hispanic (NH) Asian, NH black, Hispanic, and NH white patients while controlling for other risk factors such as age, sex, and SEER geographic region. RESULTS Total costs and hospital utilization were, on average, greater among racial-ethnic minorities compared with NH white patients in the last month of life. Among patients with NSCLC, the relative total costs were 1.27 (95% confidence interval [CI], 1.21-1.33) for NH black patients, 1.36 (95% CI, 1.25-1.49) for NH Asian patients, and 1.21 (95% CI, 1.07-1.38) for Hispanic patients. Additionally, the odds of being admitted to a hospital for NH black, NH Asian, and Hispanic patients were 1.22 (95% CI, 1.15-1.30), 1.47 (95% CI, 1.32-1.63), and 1.18 (95% CI, 1.01-1.38) times that of NH white patients, respectively. Similar results were found for patients with SCLC. CONCLUSION Minority patients with lung cancer have significantly higher end-of-life medical expenditures than NH white patients, which may be explained by a greater intensity of care in the end-of-life period. IMPLICATIONS FOR PRACTICE This study investigated racial-ethnic disparities in the cost and utilization of medical care among lung cancer patients during the end-of-life period. Compared with non-Hispanic white patients, racial-ethnic minority patients were more likely to receive intensive care in their final month of life and had statistically significantly higher end-of-life care costs. The findings of this study may lead to a better understanding of the racial-ethnic disparities in end-of-life care, which can better inform future end-of-life interventions and help health care providers develop less intensive and more equitable care, such as culturally competent advanced care planning programs, for all patients.
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Affiliation(s)
- Yufan Chen
- Institute for Technology Assessment, Massachusetts General HospitalBostonMassachusettsUSA
| | - Steven D. Criss
- Institute for Technology Assessment, Massachusetts General HospitalBostonMassachusettsUSA
| | - Tina R. Watson
- Institute for Technology Assessment, Massachusetts General HospitalBostonMassachusettsUSA
| | - Andrew Eckel
- Institute for Technology Assessment, Massachusetts General HospitalBostonMassachusettsUSA
| | - Lauren Palazzo
- Institute for Technology Assessment, Massachusetts General HospitalBostonMassachusettsUSA
| | - Angela C. Tramontano
- Institute for Technology Assessment, Massachusetts General HospitalBostonMassachusettsUSA
| | - Ying Wang
- BC Cancer VancouverVancouverBritish ColumbiaCanada
| | - Nathaniel D. Mercaldo
- Institute for Technology Assessment, Massachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Chung Yin Kong
- Institute for Technology Assessment, Massachusetts General HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
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Udelsman BV, Govea N, Cooper Z, Chang DC, Bader A, Meyer MJ. Concordance in advance care preferences among high-risk surgical patients and surrogate health care decision makers in the perioperative setting. Surgery 2019; 167:396-403. [PMID: 31668357 DOI: 10.1016/j.surg.2019.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 08/09/2019] [Accepted: 08/17/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Earlier studies have demonstrated poor concordance between patients' advance care preferences and those endorsed by their surrogate health care decision makers in a medical setting. This study aimed to determine concordance in the perioperative setting among high-risk patients and to identify areas for improvement. METHODS This was a prospective cohort study set in a preoperative clinic for high-risk patients. Patients (>55 y) and their surrogates (dyads) were eligible for participation. Dyads were surveyed on the patient's desire for advance care preferences (cardiopulmonary resuscitation, mechanical ventilation, hemodialysis, artificial nutrition) and tolerance for physical disability, cognitive disability, and chronic pain. Concordance was defined as the surrogate correctly predicting patient preferences. Patients and surrogates were resurveyed for concordance 30 to 60 d after the index procedure. RESULTS A total of 100 dyads (200 subjects) completed the survey. Median patient age was 68 y. Most patients were white (87%) and had an American Society of Anesthesiologists score of III (88%). The majority of dyads (59%) reported prior conversations about advance care preferences. Concordance specifically for cardiopulmonary resuscitation was 84%. In all other domains, <60% of dyads achieved concordance. Prior conversations regarding advance care preferences did not improve concordance in univariable or multivariable analysis. In postoperative surveys, substantial improvement was found in all domains except mechanical ventilation and cardiopulmonary resuscitation. CONCLUSION In all domains except cardiopulmonary resuscitation, concordance was <60% in the preoperative setting and was not improved among dyads who reported prior conversations regarding advance care preferences. Discordance may limit patient autonomy by prolonging undesired interventions or terminating desired interventions prematurely.
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Affiliation(s)
| | - Nicolas Govea
- Department of Anesthesiology, NewYork-Presbyterian-Weill Cornell Medical Center, New York, NY
| | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Boston, MA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Angela Bader
- Center for Surgery and Public Health, Boston, MA; Department of Anesthesiology, Brigham and Women's Hospital, Boston, MA
| | - Matthew J Meyer
- Department of Anesthesiology, University of Virginia, Charlottesville, VA
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Dover LL, Dulaney CR, Williams CP, Fiveash JB, Jackson BE, Warren PP, Kvale EA, Boggs DH, Rocque GB. Hospice care, cancer-directed therapy, and Medicare expenditures among older patients dying with malignant brain tumors. Neuro Oncol 2019; 20:986-993. [PMID: 29156054 DOI: 10.1093/neuonc/nox220] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background End-of-life care for older adults with malignant brain tumors is poorly understood. The purpose of this study is to quantify end-of-life utilization of hospice care, cancer-directed therapy, and associated Medicare expenditures among older adults with malignant brain tumors. Methods This retrospective cohort study included deceased Medicare beneficiaries age ≥65 with primary malignant brain tumor (PMBT) or secondary MBT (SMBT) receiving care within a southeastern cancer community network including academic and community hospitals from 2012-2015. Utilization of hospice and cancer-directed therapy and total Medicare expenditures in the last 30 days of life were calculated using generalized linear and mixed effect models, respectively. Results Late (1-3 days prior to death) or no hospice care was received by 24% of PMBT (n = 383) and 32% of SMBT (n = 940) patients. SMBT patients received late hospice care more frequently than PMBT patients (10% vs 5%, P = 0.002). Cancer-directed therapy was administered to 18% of patients with PMBT versus 25% with SMBT (P = 0.003). Nonwhite race, male sex, and receipt of any hospital-based care in the final 30 days of life were associated with increased risk of late or no hospice care. The average decrease in Medicare expenditures associated with hospice utilization for patients with PMBT was $-12,138 (95% CI: $-18,065 to $-6210) and with SMBT was $-1,508 (95% CI: $-3,613 to $598). Conclusions Receiving late or no hospice care was common among older patients with malignant brain tumors and was significantly associated with increased total Medicare expenditures for patients with PMBT.
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Affiliation(s)
- Laura L Dover
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Caleb R Dulaney
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Courtney P Williams
- Department of Medicine, Division of Hematology-Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - John B Fiveash
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bradford E Jackson
- Center for Outcomes Research, John Peter Smith Hospital Health Network, Fort Worth, Texas
| | - Paula P Warren
- Department of Neurology, Division of Neuro-Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth A Kvale
- Department of Medicine, Division of Palliative Medicine, University of Alabama at Birmingham, Birmingham, Alabama.,Birmingham VA Medical Center, Birmingham Alabama
| | - D Hunter Boggs
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gabrielle B Rocque
- Department of Medicine, Division of Hematology-Oncology, University of Alabama at Birmingham, Birmingham, Alabama.,Department of Medicine, Division of Palliative Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Abstract
This review proposes that the end of life is a uniquely contemporary life course stage. Epidemiologic, technological, and cultural shifts over the past two centuries have created a context in which dying has shifted from a sudden and unexpected event to a protracted, anticipated transition following an incurable chronic illness. The emergence of an end-of-life stage lasting for months or even years has heightened public interest in enhancing patient well-being, autonomy, and the receipt of medical care that accords with patient and family members' wishes. We describe key components of end-of-life well-being and highlight socioeconomic and race disparities therein, drawing on fundamental cause theory. We describe two practices that are critical to end-of-life well-being (advance care planning and hospice) and identify limitations that may undermine their effectiveness. We conclude with recommendations for future sociological research that could inform practices to enhance patient and family well-being at the end of life.
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Affiliation(s)
- Deborah Carr
- Department of Sociology, Boston University, Boston, Massachusetts 02215, USA
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Gutierrez C, Hsu W, Ouyang Q, Yao H, Pollack S, Pan CX. Palliative Care Intervention in the Intensive Care Unit: Comparing Outcomes among Seriously Ill Asian Patients and those of Other Ethnicities. J Palliat Care 2018. [DOI: 10.1177/082585971403000304] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: The literature describing the attitude of Asians toward palliative care in the intensive care unit (ICU) is scarce. Aim: The purpose of this study was to compare outcomes of Asians and people of other ethnicities after palliative care intervention in the ICU. Methods: A retrospective chart review was conducted of all ICU patients evaluated by palliative care; the outcomes measured were incidence of life-sustaining treatments, institution of advance care directives, and preferences for end-of-life care. Results: The palliative care team evaluated 119 patients (46.2 percent Caucasian, 27.2 percent Asian, and 26.1 percent other ethnicities). There were no differences in demographics or clinical variables. Thirty-six percent of the Asians, 49 percent of the Caucasians, and 28.6 percent of the patients of other ethnicities (p=0.19) had healthcare proxies. The palliative care team increased advance care directives by more than 40 percent in all groups (p<0.001). There were no differences in the use of life-sustaining treatments or preferences for comfort measures among ethnic groups. Conclusion: Asians are as likely as people of other ethnicities to decide on advance care directives, life-sustaining treatments, and comfort measures after palliative care evaluation in the ICU. Contexte: Il existe très peu de publications décrivant l'attitude des asiatiques envers l'intervention des spécialistes en soins palliatifs dans le service de soins intensifs. But: Cette étude avait pour but de comparer les résultats obtenus chez les asiatiques et d'autres groupes ethniques après l'intervention de ces spécialistes auprès des patients et de leur famille dans le service de soins intensifs. Méthode: On a fait l'analyse rétrospective des dossiers de tous les patients ayant été rencontrés par l'équipe de soins palliatifs; les résultats de l'analyse portaient sur la fréquence des traitements de prolongation de vie, les directives de fin de vie, et les préférences des patients en ce qui avait trait aux soins de fin de vie. Résultats: L'équipe de soins palliatifs a évalué les dossiers de 119 patients (46,2 pourcent d'origine caucasienne, 27,2 pourcent d'origine asiatique, et 26,1 pourcent de diverses origines). Trente-six pourcent des asiatiques, 49 pourcent des caucasiens, et 28,6 pourcent des autres ethniques (p=19) avaient déjà choisi leur mandataire légal. L'équipe de soins palliatifs a augmenté le recours aux directives de fin de vie par plus de 40 pourcent dans tous les groupes (p=<0,001). Il n'y avait aucune différence entre ces groupes quant au recours aux traitements de fin de vie et aux mesures de confort du patient. Conclusion: Suite à une rencontre avec l'équipe de soins palliatifs, les asiatiques, tout comme les autres groupes ethniques, sont tout autant susceptibles de décider de leurs traitements de fin de vie et de recourir aux mesures de confort et aux directives préalables.
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Affiliation(s)
- Cristina Gutierrez
- Critical Care Medicine Service, Department of Medicine, New York Hospital Queens, 56–45 Main Street, Room WA-100, Flushing, New York 11355, USA
| | - William Hsu
- Internal Medicine, Department of Medicine, New York Hospital Queens, Flushing, New York, USA
| | - Qin Ouyang
- Internal Medicine, Department of Medicine, New York Hospital Queens, Flushing, New York, USA
| | - Haijun Yao
- Department of Pathology and Laboratory, Lutheran Medical Center, Brooklyn, New York, USA
| | - Simcha Pollack
- Computer Information Systems and Decision Sciences, Tobin College of Business, St. John's University, Jamaica, New York, USA
| | - Cynthia X. Pan
- Geriatrics and Palliative Care Medicine, Department of Medicine, New York Hospital Queens, Flushing, New York, USA
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Luth EA, Prigerson HG. Unintended Harm? Race Differences in the Relationship Between Advance Care Planning and Psychological Distress at the End of Life. J Pain Symptom Manage 2018; 56:752-759. [PMID: 30096438 PMCID: PMC6195838 DOI: 10.1016/j.jpainsymman.2018.08.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/01/2018] [Accepted: 08/01/2018] [Indexed: 11/16/2022]
Abstract
CONTEXT Research has revealed racial disparities in advance care planning and intensity of end-of-life care. Studies of the relationship between advance care planning and sadness and anxiety at the end of life are inconclusive. OBJECTIVES The objective of this study was to determine the extent to which the relationship between advance care planning and sadness and anxiety at the end of life differs by race. METHODS This study analyzes data from 315 Medicare beneficiaries from the 2011-2016 National Health and Aging Trends Study. Caregiver-assessed sadness/anxiety at decedent's end of life was categorized as none, managed needs, and unmanaged needs. We used multinomial logistic regression and calculated relative risk and predicted probability of reporting sadness/anxiety by race and advance care planning status, controlling for demographic and health characteristics. RESULTS Among non-Hispanic black/African-Americans who died, end-of-life discussions and having a health care proxy increased the predicted probability of caregivers reporting unmanaged needs related to sadness/anxiety by factors of 2.6 and 3.5, respectively (discussions: from 15% to 39%, P = 0.03; health care proxy: from 12% to 42%, P = 0.008). By contrast, among non-Hispanic white decedents, end-of-life discussions and naming a health care proxy were not associated with caregivers reporting unmanaged needs related to sadness/anxiety. CONCLUSION Advance care planning may not work the same way for black and white individuals. End-of-life discussions and naming a health care proxy are potentially harmful to dying black patients' mental health. This finding suggests a need for additional research to understand why caregivers report unmanaged sadness/anxiety for dying black patients who engaged in advance care planning and increased attention to these patients' mental health at the end of life.
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A Population-Based Study of Intracerebral Hemorrhage Survivors' Outcomes. J Stroke Cerebrovasc Dis 2018; 28:49-55. [PMID: 30274873 DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 07/10/2018] [Accepted: 09/02/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND We evaluated 3-month neurologic, functional, cognitive, and quality of life (QOL) outcomes in intracerebral hemorrhage (ICH) overall, and by sex and ethnicity in a population-based study. METHODS Spontaneous ICH patients were identified from the Brain Attack Surveillance in Corpus Christi project (November 2008 to December 2013). Outcomes included neurologic (National Institutes of Health Stroke Scale: range 0-42), functional (activities of daily living/instrumental activities of daily living score: range 1-4, higher worse), cognitive (Modified Mini-Mental State Examination [3MSE]: range 0-100), and QOL (short-form stroke-specific QOL scale: range 0-5, higher better). Ethnic and sex differences were assessed with Tobit regression adjusted for age, sex, or ethnicity, and presenting Glasgow coma scale. RESULTS A total of 245 patients completed baseline interviews, with 103 (42%) dying prior to follow-up, leaving 142 eligible for outcome assessment. Three-month follow-up was completed in 100 (neurologic), 107 (functional), 79 (cognitive), and 83 (QOL) participants. Median age was 66 years (interquartile range 58.0-77.0). Cognitive outcomes were worse in Mexican Americans (MA) compared to non-Hispanic whites (NHW) after multivariable adjustment (MA scoring 13.3 3MSE points lower than NHW [95% confidence interval: 5.8, 20.7; P = .0005]). There was no difference by sex or ethnicity in neurological, functional, or QOL outcomes, and no sex differences in cognitive outcomes. CONCLUSIONS In this population-based study, worse cognitive outcomes were found in MAs compared with NHW. There were no differences between neurologic, functional, and QOL outcomes in ICH survivors based on sex or ethnicity.
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Marsack J, Stephenson R. Barriers to End-of-Life Care for LGBT Persons in the Absence of Legal Marriage or Adequate Legal Documentation. LGBT Health 2018; 5:273-283. [PMID: 29920158 DOI: 10.1089/lgbt.2016.0182] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
End-of-life care has attracted increased attention in recent years due to increases in both the number and mean age of the world's population; however, the experiences of LGBT persons during end-of-life care remain understudied. Given the health disparities and barriers to care experienced throughout the life course of LGBT persons, the frequent involvement of legal spouses in end-of-life care, and the recency of marriage equality, it can be surmised that LGBT persons might experience significantly different barriers to their desired end-of-life care compared to their heterosexual and cisgender counterparts. This article aims to synthesize what is known about these barriers, particularly in the absence of legal marriage or protective legal documentation. Of two hundred and twelve articles reviewed, twenty-three were included for analysis. Common barriers that emerged were discriminatory laws (e.g., prohibitions against same-sex marriage) and policies, lack of decision-making capacity, lack of knowledge regarding patient wishes, lack of visitation rights, challenges from biological next of kin, and discrimination and psychological distress. Recommendations for future research are provided based on gaps that were identified. These include increased research on transgender persons and bisexual persons, and on providers of end-of-life care. In addition, the recommendations take into account that important legislative and policy changes occurred after the period in which the studies reviewed here were published. The impact of those changes cannot be reported in this study and should be determined by future studies. This synthesis provides the contextual understanding necessary for research and improvement in this vastly understudied area.
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Affiliation(s)
- Jessica Marsack
- Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, and The Center for Sexuality and Health Disparities, University of Michigan , Ann Arbor, Michigan
| | - Rob Stephenson
- Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, and The Center for Sexuality and Health Disparities, University of Michigan , Ann Arbor, Michigan
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Brown CE, Engelberg RA, Sharma R, Downey L, Fausto JA, Sibley J, Lober W, Khandelwal N, Loggers ET, Curtis JR. Race/Ethnicity, Socioeconomic Status, and Healthcare Intensity at the End of Life. J Palliat Med 2018; 21:1308-1316. [PMID: 29893618 DOI: 10.1089/jpm.2018.0011] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although racial/ethnic minorities receive more intense, nonbeneficial healthcare at the end of life, the role of race/ethnicity independent of other social determinants of health is not well understood. OBJECTIVES Examine the association between race/ethnicity, other key social determinants of health, and healthcare intensity in the last 30 days of life for those with chronic, life-limiting illness. SUBJECTS We identified 22,068 decedents with chronic illness cared for at a single healthcare system in Washington State who died between 2010 and 2015 and linked electronic health records to death certificate data. DESIGN Binomial regression models were used to test associations of healthcare intensity with race/ethnicity, insurance status, education, and median income by zip code. Path analyses tested direct and indirect effects of race/ethnicity with insurance, education, and median income by zip code used as mediators. MEASUREMENTS We examined three measures of healthcare intensity: (1) intensive care unit admission, (2) use of mechanical ventilation, and (3) receipt of cardiopulmonary resuscitation. RESULTS Minority race/ethnicity, lower income and educational attainment, and Medicaid and military insurance were associated with higher intensity care. Socioeconomic disadvantage accounted for some of the higher intensity in racial/ethnic minorities, but most of the effects were direct effects of race/ethnicity. CONCLUSIONS The effects of minority race/ethnicity on healthcare intensity at the end of life are only partly mediated by other social determinants of health. Future interventions should address the factors driving both direct and indirect effects of race/ethnicity on healthcare intensity.
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Affiliation(s)
- Crystal E Brown
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
| | - Ruth A Engelberg
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
| | - Rashmi Sharma
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,3 Division of General Internal Medicine, University of Washington , Seattle, Washington
| | - Lois Downey
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
| | - James A Fausto
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,4 Department of Family Medicine, University of Washington , Seattle, Washington
| | - James Sibley
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,5 Department of Bioinformatics and Medical Education, University of Washington , Seattle, Washington
| | - William Lober
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,5 Department of Bioinformatics and Medical Education, University of Washington , Seattle, Washington
| | - Nita Khandelwal
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,6 Department of Anesthesiology and Pain Medicine, University of Washington , Seattle, Washington
| | - Elizabeth T Loggers
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,7 Seattle Cancer Care Alliance , Seattle, Washington.,8 Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle, Washington
| | - J Randall Curtis
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
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Does Admission to the ICU Prevent African American Disparities in Withdrawal of Life-Sustaining Treatment? Crit Care Med 2017; 45:e1083-e1086. [PMID: 28471815 DOI: 10.1097/ccm.0000000000002478] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We sought to determine whether black patients admitted to an ICU were less likely than white patients to withdraw life-sustaining treatments. DESIGN We performed a retrospective cohort study of hospital discharges from October 20, 2015, to October 19, 2016, for inpatients 18 years old or older and recorded those patients, along with their respective races, who had an "Adult Comfort Care" order set placed prior to discharge. A two-sample test for equality of two proportions with continuity correction was performed to compare the proportions between blacks and whites. SETTING University of Florida Health. PATIENTS The study cohort included 29,590 inpatient discharges, with 21,212 Caucasians (71.69%), 5,825 African Americans (19.69%), and 2,546 non-Caucasians/non-African Americans (8.62%). INTERVENTIONS Withdrawal of life-sustaining treatments. MEASUREMENTS AND MAIN RESULTS Of the total discharges (n = 29,590), 525 (1.77%) had the Adult Comfort Care order set placed. Seventy-eight of 5,825 African American patients (1.34%) had the Adult Comfort Care order set placed, whereas 413 of 21,212 Caucasian patients (1.95%) had this order set placed (p = 0.00251; 95% CI, 0.00248-0.00968). Of the 29,590 patients evaluated, 6,324 patients (21.37%) spent at least one night in an ICU. Of these 6,324 patients, 4,821 (76.24%) were white and 1,056 (16.70%) were black. Three hundred fifty of 6,324 (5.53%) were discharged with an Adult Comfort Care order set. Two hundred seventy-one White patients (5.62%) with one night in an ICU were discharged with an Adult Comfort Care order set, whereas 54 Black patients (5.11%) with one night in an ICU had the order set (p = 0.516). CONCLUSIONS This study suggests that Black patients may be less likely to withdraw life-supportive measures than whites, but that this disparity may be absent in patients who spend time in the ICU during their hospitalization.
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van der Heide A, Vrakking A, van Delden H, Looman C, van der Maas P. Medical and Nonmedical Determinants of Decision Making about Potentially Life-Prolonging Interventions. Med Decis Making 2016; 24:518-24. [PMID: 15359001 DOI: 10.1177/0272989x04268952] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patient characteristics may influence medical decision making in various ways. The contribution of several patient characteristics to medical decision making was studied. Thirty oncologists, 29 nursing home physicians, and 22 cardiologistswere interviewed (overall response = 60%). Respondents were asked whether they would apply a specified intervention for a number of hypothetical seriously ill patients, who varied with respect to factors thatwere not relevant to the outcome of treatment. The condition that made patients clearly eligible for treatment was kept constant. In amultivariate regression model, patients with a better physical condition, a more obvious social role, and a lower age weremore likely to be treated thanwere other patients. Medical decision making is not exclusively based on empirical evidence but also related to morally complex issues such as patient age and social status.
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Affiliation(s)
- Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands.
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Check DK, Samuel CA, Rosenstein DL, Dusetzina SB. Investigation of Racial Disparities in Early Supportive Medication Use and End-of-Life Care Among Medicare Beneficiaries With Stage IV Breast Cancer. J Clin Oncol 2016; 34:2265-70. [PMID: 27161968 PMCID: PMC4962709 DOI: 10.1200/jco.2015.64.8162] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Early supportive care may improve quality of life and end-of-life care among patients with cancer. We assessed racial disparities in early use of medications for common cancer symptoms (depression, anxiety, insomnia) and whether these potential disparities modify end-of-life care. METHODS We used 2007 to 2012 SEER-Medicare data to evaluate use of supportive medications (opioid pain medications and nonopioid psychotropics, including antidepressants/anxiolytics and sleep aids) in the 90 days postdiagnosis among black and white women with stage IV breast cancer who died between 2007 and 2012. We used modified Poisson regression to assess the relationship between race and supportive treatment use and end-of-life care (hospice, intensive care unit, more than one emergency department visit or hospitalization 30 days before death, in-hospital death). RESULTS The study included 752 white and 131 black women. We observed disparities in nonopioid psychotropic use between black and white women (adjusted risk ratio [aRR], 0.51; 95% CI, 0.35 to 0.74) but not in opioid pain medication use. There were also disparities in hospice use (aRR, 0.86; 95% CI, 0.74 to 0.99), intensive care unit admission or more than one emergency department visit or hospitalization 30 days before death (aRR, 1.28; 95% CI, 1.01 to 1.63), and risk of dying in the hospital (aRR, 1.59; 95% CI, 1.22 to 2.09). Supportive medication use did not attenuate end-of-life care disparities. CONCLUSION We observed racial disparities in early supportive medication use among patients with stage IV breast cancer. Although they did not clearly attenuate end-of-life care disparities, medication use disparities may be of concern if they point to disparities in adequacy of symptom management given the potential implications for quality of life.
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Affiliation(s)
- Devon K Check
- All authors: University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Cleo A Samuel
- All authors: University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Stacie B Dusetzina
- All authors: University of North Carolina at Chapel Hill, Chapel Hill, NC
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Long AC, Downey L, Engelberg RA, Ford DW, Back AL, Curtis JR. Physicians' and Nurse Practitioners' Level of Pessimism About End-of-Life Care During Training: Does It Change Over Time? J Pain Symptom Manage 2016; 51:890-897.e1. [PMID: 26826677 PMCID: PMC4875853 DOI: 10.1016/j.jpainsymman.2015.11.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 11/27/2015] [Accepted: 12/01/2015] [Indexed: 10/22/2022]
Abstract
CONTEXT An enhanced understanding of trainee attitudes about end-of-life care is needed to inform interventions to improve clinician communication about dying and death. OBJECTIVES To examine changes in trainee pessimism about end-of-life care over the course of one academic year and to explore predictors of pessimism among residents, fellows, and nurse practitioners. METHODS We used baseline and follow-up surveys completed by trainees during a randomized controlled trial of an intervention to improve clinician communication skills. Surveys addressed trainee feelings about end-of-life care. Latent variable modeling was used to identify indicators of trainee pessimism, and this pessimism construct was used to assess temporal changes in trainee attitudes about end-of-life care. We also examined predictors of trainee pessimism at baseline and follow-up. Data were available for 383 trainees from two training programs. RESULTS There was a significant decrease in pessimism between baseline and follow-up assessments. Age had a significant inverse effect on baseline pessimism, with older trainees being less pessimistic. There was a direct association of race/ethnicity on pessimism at follow-up, with greater pessimism among minority trainees (P = 0.028). The model suggests that between baseline and follow-up, pessimism among younger white non-Hispanic trainees decreased, whereas pessimism among younger trainees in racial/ethnic minorities increased over the same period. CONCLUSION Overall, trainee pessimism about end-of-life care decreases over time. Pessimism about end-of-life care among minority trainees may reflect the influence of culture on clinician attitudes about communication with seriously ill patients. Further research is needed to understand the evolution of trainee attitudes about end-of-life care during clinical training.
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Affiliation(s)
- Ann C Long
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.
| | - Lois Downey
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - Dee W Ford
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Anthony L Back
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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Jordan K, Elliott JO, Wall S, Saul E, Sheth R, Coffman J. Associations with resuscitation choice: Do not resuscitate, full code or undecided. PATIENT EDUCATION AND COUNSELING 2016; 99:823-829. [PMID: 26673106 DOI: 10.1016/j.pec.2015.11.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 11/11/2015] [Accepted: 11/28/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To examine associations of individual exposure and knowledge of resuscitation mechanics and prognosis with specific decision: Do Not Resuscitate (DNR), Full Code (FC) or Undecided (UD). METHODS Cross-sectional questionnaire at 3 sites: geriatric assessment center, internal medicine resident clinic, and inpatient palliative care service. RESULTS 407 completed the questionnaire: 27% identified as DNR, 24% as FC and 49% as UD. Few (11.8%) respondents reported discussion of DNR status with their primary care doctor. DNR choice was associated with knowledge of DNR mechanics, OR=2.30 (95%CI: 1.23-4.30), physician discussion, OR=5.58 (95%CI: 2.39-13.04) and confidence in understanding own health problems, OR=2.89 (95%CI: 1.04-8.04). FC choice was associated with knowledge of FC mechanics, OR=2.01 (95%CI: 1.03-3.93) and media code exposure, OR=3.80 (95%CI: 1.46-9.92). Knowledge of resuscitation prognosis was negatively associated with FC, OR =0.48 (95%CI: 0.23-0.98). CONCLUSION Many individuals lack knowledge or understanding of resuscitation procedure, its risks, and prognosis. Educational efforts, for both patients and healthcare professionals, are needed to improve individual knowledge needed for informed decision. PRACTICE IMPLICATIONS Scheduled time for physician-patient discussion remains important for education about individual health conditions and risk/benefits related to resuscitation.
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Affiliation(s)
- Kim Jordan
- Department of Internal Medicine, Riverside Methodist Hospital, United States.
| | | | - Sarah Wall
- Section of Hematology and Oncology, The Ohio State University, United States
| | - Emily Saul
- Section of Hematology and Oncology, University of Mississippi, United States
| | - Rajiv Sheth
- Central Ohio Primary Care Physicians, United States
| | - Julie Coffman
- Department of Internal Medicine, Riverside Methodist Hospital, United States
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Peinado-Gorlat P, Castro-Martínez FJ, Arriba-Marcos B, Melguizo-Jiménez M, Barrio-Cantalejo I. Roma Women's Perspectives on End-of-Life Decisions. JOURNAL OF BIOETHICAL INQUIRY 2015; 12:687-698. [PMID: 26280159 DOI: 10.1007/s11673-015-9656-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 02/01/2015] [Indexed: 06/04/2023]
Abstract
Spain's Roma community has its own cultural and moral values. These values influence the way in which end-of-life decision-making is confronted. The objective of this study was to explore the perspective of Roma women on end-of-life decision-making. It was a qualitative study involving thirty-three Roma women belonging to groups for training and social development in two municipalities. We brought together five focus groups between February and December 2012. Six mediators each recruited five to six participants. We considered age and care role to be the variables that can have the most influence on opinion regarding end-of-life decision-making. We considered the discussion saturated when the ideas expressed were repeated. Data analysis was carried out according to five steps: describing, organizing, connecting, corroborating/legitimating, and representing the account. The main ideas gleaned from the data were as follows: (1) the important role of the family in end-of-life care, especially the role of women; (2) the large influence of community opinion over personal or family decisions, typical of closed societies; (3) the different preferences women had for themselves compared to that for others regarding desired end-of-life care; (4) unawareness or rejection of advance directives. Roma women wish for their healthcare preferences to be taken into account, but "not in writing." The study concluded that the success of end-of-life healthcare in Roma families and of their involvement in the making of healthcare decisions depends upon considering and respecting their idiosyncrasy.
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Affiliation(s)
| | | | - Beatriz Arriba-Marcos
- Albaycin Primary Health Care Centre, Metropolitan-Granada Health District, Granada, Spain
| | | | - Inés Barrio-Cantalejo
- Almanjayar Primary Health Care Centre, Metropolitan-Granada Health District, Granada, Spain
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"Do not resuscitate" decisions in acute respiratory distress syndrome. A secondary analysis of clinical trial data. Ann Am Thorac Soc 2015; 11:1592-6. [PMID: 25386717 DOI: 10.1513/annalsats.201406-244bc] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE Factors and outcomes associated with end-of-life decision-making among patients during clinical trials in the intensive care unit are unclear. OBJECTIVES We sought to determine patterns and outcomes of Do Not Resuscitate (DNR) decisions among critically ill patients with acute respiratory distress syndrome (ARDS) enrolled in a clinical trial. METHODS We performed a secondary analysis of data from the ARDS Network Fluid and Catheter Treatment Trial (FACTT), collected between 2000 and 2005. We calculated mortality outcomes stratified by code status, and compared baseline characteristics of patients who became DNR during the trial with participants who remained full code. MEASUREMENTS AND MAIN RESULTS Among 809 FACTT participants with a code status recorded, 232 (28.7%) elected DNR status. Specifically, 37 (15.9%) chose to withhold cardiopulmonary resuscitation alone, 44 (19.0%) elected to withhold some life support measures in addition to cardiopulmonary resuscitation, and 151 (65.1%) had life support withdrawn. Admission severity of illness as measured by APACHE III score was strongly associated with election of DNR status (odds ratio, 2.2; 95% confidence interval, 1.85-2.62; P < 0.0001). Almost all (97.0%; 225 of 232) patients who selected DNR status died, and 79% (225 of 284) of patients who died during the trial were DNR. Among patients who chose DNR status but did not elect withdrawal of life support, 91% (74 of 81) died. CONCLUSIONS The vast majority of deaths among clinical trial patients with ARDS were preceded by a DNR order. Unlike other studies of end-of-life decision-making in the intensive care unit, nearly all patients who became DNR died. The impact of variation of practice in end-of-life decision-making during clinical trials warrants further study.
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Sharma RK, Cameron KA, Chmiel JS, Von Roenn JH, Szmuilowicz E, Prigerson HG, Penedo FJ. Racial/Ethnic Differences in Inpatient Palliative Care Consultation for Patients With Advanced Cancer. J Clin Oncol 2015; 33:3802-8. [PMID: 26324373 DOI: 10.1200/jco.2015.61.6458] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Inpatient palliative care consultation (IPCC) may help address barriers that limit the use of hospice and the receipt of symptom-focused care for racial/ethnic minorities, yet little is known about disparities in the rates of IPCC. We evaluated the association between race/ethnicity and rates of IPCC for patients with advanced cancer. PATIENTS AND METHODS Patients with metastatic cancer who were hospitalized between January 1, 2009, and December 31, 2010, at an urban academic medical center participated in the study. Patient-level multivariable logistic regression was used to evaluate the association between race/ethnicity and IPCC. RESULTS A total of 6,288 patients (69% non-Hispanic white, 19% African American, and 6% Hispanic) were eligible. Of these patients, 16% of whites, 22% of African Americans, and 20% of Hispanics had an IPCC (overall P < .001). Compared with whites, African Americans had a greater likelihood of receiving an IPCC (odds ratio, 1.21; 95% CI, 1.01 to 1.44), even after adjusting for insurance, hospitalizations, marital status, and illness severity. Among patients who received an IPCC, African Americans had a higher median number of days from IPCC to death compared with whites (25 v 17 days; P = .006), and were more likely than Hispanics (59% v 41%; P = .006), but not whites, to be referred to hospice. CONCLUSION Inpatient settings may neutralize some racial/ethnic differences in access to hospice and palliative care services; however, irrespective of race/ethnicity, rates of IPCC remain low and occur close to death. Additional research is needed to identify interventions to improve access to palliative care in the hospital for all patients with advanced cancer.
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Affiliation(s)
- Rashmi K Sharma
- Rashmi K. Sharma, Kenzie A. Cameron, Joan S. Chmiel, Jamie H. Von Roenn, Eytan Szmuilowicz, and Frank J. Penedo, Northwestern University, Chicago, IL; Jamie H. Von Roenn, American Society of Clinical Oncology, Alexandria, VA; and Holly G. Prigerson, Weill Cornell Medical College, New York, NY.
| | - Kenzie A Cameron
- Rashmi K. Sharma, Kenzie A. Cameron, Joan S. Chmiel, Jamie H. Von Roenn, Eytan Szmuilowicz, and Frank J. Penedo, Northwestern University, Chicago, IL; Jamie H. Von Roenn, American Society of Clinical Oncology, Alexandria, VA; and Holly G. Prigerson, Weill Cornell Medical College, New York, NY
| | - Joan S Chmiel
- Rashmi K. Sharma, Kenzie A. Cameron, Joan S. Chmiel, Jamie H. Von Roenn, Eytan Szmuilowicz, and Frank J. Penedo, Northwestern University, Chicago, IL; Jamie H. Von Roenn, American Society of Clinical Oncology, Alexandria, VA; and Holly G. Prigerson, Weill Cornell Medical College, New York, NY
| | - Jamie H Von Roenn
- Rashmi K. Sharma, Kenzie A. Cameron, Joan S. Chmiel, Jamie H. Von Roenn, Eytan Szmuilowicz, and Frank J. Penedo, Northwestern University, Chicago, IL; Jamie H. Von Roenn, American Society of Clinical Oncology, Alexandria, VA; and Holly G. Prigerson, Weill Cornell Medical College, New York, NY
| | - Eytan Szmuilowicz
- Rashmi K. Sharma, Kenzie A. Cameron, Joan S. Chmiel, Jamie H. Von Roenn, Eytan Szmuilowicz, and Frank J. Penedo, Northwestern University, Chicago, IL; Jamie H. Von Roenn, American Society of Clinical Oncology, Alexandria, VA; and Holly G. Prigerson, Weill Cornell Medical College, New York, NY
| | - Holly G Prigerson
- Rashmi K. Sharma, Kenzie A. Cameron, Joan S. Chmiel, Jamie H. Von Roenn, Eytan Szmuilowicz, and Frank J. Penedo, Northwestern University, Chicago, IL; Jamie H. Von Roenn, American Society of Clinical Oncology, Alexandria, VA; and Holly G. Prigerson, Weill Cornell Medical College, New York, NY
| | - Frank J Penedo
- Rashmi K. Sharma, Kenzie A. Cameron, Joan S. Chmiel, Jamie H. Von Roenn, Eytan Szmuilowicz, and Frank J. Penedo, Northwestern University, Chicago, IL; Jamie H. Von Roenn, American Society of Clinical Oncology, Alexandria, VA; and Holly G. Prigerson, Weill Cornell Medical College, New York, NY
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Abstract
OBJECTIVE To summarize the current literature on racial and gender disparities in critical care and the mechanisms underlying these disparities in the course of acute critical illness. DATA SOURCES MEDLINE search on the published literature addressing racial, ethnic, or gender disparities in acute critical illness, such as sepsis, acute lung injury, pneumonia, venous thromboembolism, and cardiac arrest. STUDY SELECTION Clinical studies that evaluated general critically ill patient populations in the United States as well as specific critical care conditions were reviewed with a focus on studies evaluating factors and contributors to health disparities. DATA EXTRACTION Study findings are presented according to their association with the prevalence, clinical presentation, management, and outcomes in acute critical illness. DATA SYNTHESIS This review presents potential contributors for racial and gender disparities related to genetic susceptibility, comorbidities, preventive health services, socioeconomic factors, cultural differences, and access to care. The data are organized along the course of acute critical illness. CONCLUSIONS The literature to date shows that disparities in critical care are most likely multifactorial involving individual, community, and hospital-level factors at several points in the continuum of acute critical illness. The data presented identify potential targets as interventions to reduce disparities in critical care and future avenues for research.
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Affiliation(s)
- Graciela J Soto
- 1Division of Critical Care Medicine, Department of Medicine, Jay B. Langner Critical Care Service, Montefiore Medical Center, Bronx, NY. 2Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Emory University, Grady Memorial Hospital, Atlanta, GA. 3Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
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Rubin MA, Dhar R, Diringer MN. Racial differences in withdrawal of mechanical ventilation do not alter mortality in neurologically injured patients. J Crit Care 2013; 29:49-53. [PMID: 24120091 DOI: 10.1016/j.jcrc.2013.08.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 08/20/2013] [Accepted: 08/30/2013] [Indexed: 11/18/2022]
Abstract
PURPOSE 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. MATERIALS AND METHODS 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. RESULTS 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). CONCLUSIONS 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.
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Affiliation(s)
- Michael A Rubin
- Neurology/Neurosurgery Intensive Care Unit, Washington University School of Medicine, Department of Neurology, 660 South Euclid Ave Campus Box 8111, St Louis, MO 63110 United States.
| | - Rajat Dhar
- Neurology/Neurosurgery Intensive Care Unit, Washington University School of Medicine, Department of Neurology, 660 South Euclid Ave Campus Box 8111, St Louis, MO 63110 United States
| | - Michael N Diringer
- Neurology/Neurosurgery Intensive Care Unit, Washington University School of Medicine, Department of Neurology, 660 South Euclid Ave Campus Box 8111, St Louis, MO 63110 United States
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Van Haitsma K, Curyto K, Spector A, Towsley G, Kleban M, Carpenter B, Ruckdeschel K, Feldman PH, Koren MJ. The Preferences for Everyday Living Inventory: Scale Development and Description of Psychosocial Preferences Responses in Community-Dwelling Elders. THE GERONTOLOGIST 2012; 53:582-95. [DOI: 10.1093/geront/gns102] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Fletcher JJ, Morgenstern LB, Lisabeth LD, Sánchez BN, Skolarus LE, Smith MA, Garcia NM, Zahuranec DB. A population-based analysis of ethnic differences in admission to the intensive care unit after stroke. Neurocrit Care 2012; 17:348-53. [PMID: 22892883 DOI: 10.1007/s12028-012-9770-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Mexican-Americans (MAs) have shown lower post-stroke mortality compared to non-hispanic whites (NHWs). Limited evidence suggests race/ethnic differences exist in intensive care unit (ICU) admissions following stroke. Our objective was to investigate the association of ethnicity with admission to the ICU following stroke. METHODS Cases of intracerebral hemorrhage and acute ischemic stroke were prospectively ascertained as part of the Brain Attack Surveillance in Corpus Christi (BASIC) project for the period of January 2000 through December 2009. Logistic regression models fitted within the generalized additive model framework were used to test associations between ethnicity and ICU admission and potential confounders. An interaction term between age and ethnicity was investigated in the final model. RESULTS A total 1,464 cases were included in analysis. MAs were younger, more likely to have diabetes, and less likely to have atrial fibrillation, health insurance, or high school diploma than NHWs. On unadjusted analysis, there was a trend toward MAs being more likely to be admitted to ICU than NHWs (34.6 vs 30.3 %; OR = 1.22; 95 % CI 0.98-1.52; p = 0.08). However, on adjusted analysis, no overall association between MA ethnicity and ICU admission (OR = 1.13; 95 % CI 0.85-1.50) was found. When an interaction term for age and ethnicity was added to this model, there was only borderline evidence for effect modification by age of the ethnicity/ICU relationship (p = 0.16). CONCLUSIONS No overall association between ethnicity and ICU admission was observed in this community. ICU utilization alone does not likely explain ethnic differences in survival following stroke between MAs and NHWs.
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Affiliation(s)
- Jeffrey J Fletcher
- Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, MI, USA
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Fishman JM, Ten Have T, Casarett D. Is public communication about end-of-life care helping to inform all? Cancer news coverage in African American versus mainstream media. Cancer 2012; 118:2157-62. [PMID: 21952922 PMCID: PMC4164161 DOI: 10.1002/cncr.26499] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 06/15/2011] [Accepted: 07/20/2011] [Indexed: 11/08/2022]
Abstract
BACKGROUND Because cancers are a leading cause of death, these diseases receive a great deal of news attention. However, because news media frequently target specific racial or ethnic audiences, some populations may receive different information, and it is unknown whether reporting equally informs all audiences about the options for care at the end of life. This study of news reporting compared "mainstream" (general market) media with African American media, which serves the largest minority group. The specific goal of this study was to determine whether these news media communicate differently about cure-directed cancer treatment and end-of-life alternatives. METHODS This content analysis included 660 cancer news stories from online and print media that targeted either African American or mainstream audiences. The main outcome measures included whether reporting discussed adverse events of cancer treatment, cancer treatment failure, cancer death/dying, and end-of-life palliative or hospice care. RESULTS Unadjusted and adjusted analyses indicated that the news stories in the African American media are less likely than those in mainstream media to discuss each of the topics studied. Comparing the proportions of news stories in mainstream versus African American media, 31.6% versus 13.6% discussed adverse events (odds ratio [OR], 2.92; 95% confidence interval [CI], 1.51-5.66; P = .001); 14.1% versus 4.2% mentioned treatment failure (OR, 3.79; 95% CI, 1.45-9.88; P = .006); and 11.9% versus 3.8% focused on death/dying (OR, 3.42; 95% CI, 1.39-8.38; P = .007). Finally, although very few news stories discussed end-of-life hospice or palliative care, all were found in mainstream media (7/396 vs 0/264). CONCLUSION The African American news media sampled are less likely than mainstream news media to portray negative cancer outcomes and end-of-life care. Given media's segmented audiences, these findings raise concerns that not all audiences are being informed equally well. Because media content is modifiable, there may be opportunities to improve public cancer communication.
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Affiliation(s)
- Jessica M Fishman
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Lane-Fall MB, Iwashyna TJ, Cooke CR, Benson NM, Kahn JM. Insurance and racial differences in long-term acute care utilization after critical illness. Crit Care Med 2012; 40:1143-9. [PMID: 22020247 DOI: 10.1097/ccm.0b013e318237706b] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine whether insurance coverage and race are associated with long-term acute care hospital utilization in critically ill patients requiring mechanical ventilation. DESIGN Retrospective cohort study. SETTING Nonfederal Pennsylvania hospital discharges from 2004 to 2006. PATIENTS Eligible patients were aged 18 yrs or older, of white or black race, and underwent mechanical ventilation in an intensive care unit during their hospital stay. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We used multivariable logistic regression with hospital-level random effects to determine the independent association between discharge to long-term acute care hospital, insurance status, and race after appropriate controls, including a chart-based measure of severity of illness. The primary outcome measure was discharge to long-term acute care hospital. Of 66,233 eligible patients, 84.7% were white and 15.3% were black. More white patients than black patients had commercial insurance (23.4% vs. 14.9%) compared to Medicaid (10.6% vs. 29.7%) or no insurance (1.3% vs. 2.2%). Long-term acute care hospital transfer occurred in 5.0% of patients. On multivariable analysis in patients aged younger than 65 yrs, black patients were significantly less likely to undergo long-term acute care hospital transfer (odds ratio, 0.71; p = .003), as were patients with Medicaid vs. commercial insurance (odds ratio, 0.17; p < .001). Analyzing race and insurance together and accounting for hospital-level effects, patients with Medicaid were still less likely to undergo long-term acute care hospital transfer (odds ratio, 0.18; p < .001), but race effects were no longer present (odds ratio, 1.06; p = .615). No significant race effects were seen in the Medicare-eligible population aged 65 yrs or older (odds ratio for transfer to long-term acute care hospital, 0.93; p = .359). CONCLUSIONS Differences in long-term acute care hospital utilization after critical illness appear driven by insurance status and hospital-level effects. Racial variation in long-term acute care hospital use is not seen after controlling for insurance status and is not seen in a group with uniform insurance coverage. Differential access to postacute care may be minimized by expanding commercial or Medicare insurance availability and standardizing long-term acute care admission criteria across hospitals.
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Affiliation(s)
- Meghan B Lane-Fall
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA.
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Hazin R, Giles CA. Is there a color line in death? An examination of end-of-life care in the African American community. J Natl Med Assoc 2011; 103:609-13. [PMID: 21999036 DOI: 10.1016/s0027-9684(15)30387-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Although the goals of end-of-life care and hospice are to mitigate suffering and improve quality of life for patients with terminal illnesses, they remain underutilized by a significant number of African Americans. While sociocultural issues play a role in the underutilization of these resources among African Americans, other confounding factors affect the ability of African Americans to adequately access quality care at the end of life. Here, the authors examine the various barriers preventing increased use of hospice care and palliative therapy among African Americans. A particular focus of this examination will revolve around suggestions for increasing the use of end-of-life care among African Americans in the future.
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Affiliation(s)
- Ribhi Hazin
- Faculty of Arts and Sciences, Harvard University, 41 Garden St, Cambridge, MA 02138, USA.
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Race and ethnicity in the intensive care unit: what do we know and where are we going? Crit Care Med 2011; 39:579-80. [PMID: 21330852 DOI: 10.1097/ccm.0b013e31820a85be] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lepore MJ, Miller SC, Gozalo P. Hospice use among urban Black and White U.S. nursing home decedents in 2006. THE GERONTOLOGIST 2011; 51:251-60. [PMID: 21076085 PMCID: PMC3058130 DOI: 10.1093/geront/gnq093] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Accepted: 10/12/2010] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Medicare hospice is a valuable source of quality care at the end of life, but its lower use by racial minority groups is of concern. This study identifies factors associated with hospice use among urban Black and White nursing home (NH) decedents in the United States. DESIGN AND METHODS Multiple data sources are combined and multilevel logistic regression is utilized to examine hospice use among urban Black and White NH residents who had access to hospice and died in 2006 (N = 288,202). RESULTS In NHs, Blacks are less likely to use hospice than Whites (35.4% vs. 39.3%), even when controlling for covariates, interactions, and clustering of decedents in NHs and counties (adjusted odds ratio = 0.81, 95% confidence interval = 0.77-0.86). Variation in hospice use is greater among subgroups of Blacks than between Blacks and Whites, and these variations are predominantly due to individual-level factors, with some influence of NH-level factors. Hospice use is higher for Blacks versus Whites with do-not-resuscitate orders and lower for Blacks versus Whites with congestive heart failure (CHF). Additionally, hospice use is greater among Blacks with versus without do-not-resuscitate or do-not-hospitalize orders or cancer and those in low-tier versus other NHs. There was also lower hospice use among Blacks with versus without CHF. IMPLICATIONS Efforts to reduce racial differences in hospice use should attend to individual-level factors. Heightening use of advance directives and targeting Blacks with CHF for hospice could be particularly helpful.
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Affiliation(s)
- Michael J Lepore
- Department of Community Health, Center for Gerontology and Health Care Research, Brown University, Providence, RI 02912, USA.
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