Racial differences exist for a number of health conditions, services, and outcomes, including end-of-life (EOL) care.
Objective:
The aim of the study was to examine differences in processes of care in the last 7 days of life between African American and white inpatients.
Methods:
Secondary analysis was conducted of data collected in the Best Practices for End-of-Life Care for Our Nation's Veterans (BEACON) trial (conducted 2005–2011). Subjects were 4891 inpatient decedents in six Veterans Administration Medical Centers. Data were abstracted from decedents' medical records. Multi-variable analyses were conducted to examine the relationship between race and each of 18 EOL processes of care controlling for patient characteristics, study site, year of death, and whether the observation was pre- or post-intervention.
Results:
The sample consisted of 1690 African American patients (34.6%) and 3201 white patients (65.4%). African Americans were less likely to have: do not resuscitate (DNR) orders (odds ratio [OR]: 0.67; p = 0.004), advance directives (OR: 0.71; p = 0.023), active opioid orders (OR: 0.64, p = 0.0008), opioid medications administered (OR: 0.61, p = 0.004), benzodiazepine orders (OR: 0.68, p < 0.0001), benzodiazepines administered (OR: 0.61, p < 0.0001), antipsychotics administered (OR: 0.73, p = 0.004), and steroids administered (OR: 0.76, p = 0.020). Racial differences were not found for other processes of care, including palliative care consultation, pastoral care, antipsychotic and steroid orders, and location of death.
Conclusions:
Racial differences exist in some but not all aspects of EOL care. Further study is needed to understand the extent to which racial differences reflect different patient needs and preferences and whether interventions are needed to reduce disparities in patient/family education or access to quality EOL care.
Get full access to this article
View all access options for this article.
References
1.
Institute of Medicine: How Far Have We Come in Reducing Health Disparities. Washington, D.C., 2012.
2.
Institute of Medicine: Challenges and Successes in Reducing Health Disparities. Washington, D.C., 2008.
3.
Institute of Medicine: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, D.C., 2003.
4.
Institute of Medicine: Toward Health Equity and Patient-Centeredness: Integrating Health Literacy, Disparities Reduction, and Quality Improvement. Washington, D.C., 2009.
Centers for Disease Control and Prevention: CDC Health Disparities and Inequality Report-United States, 2013. Atlanta, GA, 2013.
7.
Agency for Healthcare Research and Quality: 2012National Healthcare Disparities Report. Rockville, MD, 2012.
8.
Institute of Medicine: Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, D.C., 2014.
9.
JohnsonKS, KuchibhatlaM, PayneR, et al.: Race and residence: Intercounty variation in black-white differences in hospice use. J Pain Symptom Manage, 2013; 46:681–690.
10.
LiS, ChenA, MeadK: Racial disparities in the use of cardiac revascularization: Does local hospital capacity matter?. PLoS One, 2013; 8:e69855.
11.
CramP, BaymanL, PopescuI, Vet al.: Racial disparities in revascularization rates among patients with similar insurance coverage. J Natl Med Assoc, 2009; 101:1132–1139.
12.
ShahA, ChaoKS, OstbyeT, et al.: Trends in racial disparities in pancreatic cancer surgery. J Gastrointest Surg, 2013; 17:1897–1906.
13.
WilliamsCD, StechuchakKM, ZulligLL, et al.: Influence of comorbidity on racial differences in receipt of surgery among US veterans with early-stage non-small-cell lung cancer. J Clin Oncol, 2013; 31:475–481.
14.
MeagherAD, BeadlesCA, DooreyJ, et al.: Racial and ethnic disparities in discharge to rehabilitation following traumatic brain injury. J Neurosurg, 2014:1–7.
15.
FreburgerJK, HolmesGM, KuLJ: Postacute rehabilitation care for hip fracture: Who gets the most care?. J Am Geriatr Soc, 2012; 60:1929–1935.
16.
KwakJ, HaleyWE, ChiribogaDA: Racial differences in hospice use and in-hospital death among Medicare and Medicaid dual-eligible nursing home residents. Gerontologist, 2008; 48:32–41.
17.
MorV, PapandonatosG, MillerSC: End-of-life hospitalization for African American and non-Latino white nursing home residents: Variation by race and a facility's racial composition. J Palliat Med, 2005; 8:58–68.
18.
ZhengNT, MukamelDB, CaprioT, et al.: Racial disparities in in-hospital death and hospice use among nursing home residents at the end of life. Med Care, 2011; 49:992–998.
19.
SmithAK, EarleCC, McCarthyEP: Racial and ethnic differences in end-of-life care in fee-for-service Medicare beneficiaries with advanced cancer. J Am Geriatr Soc, 2009; 57:153–158.
20.
MiesfeldtS, MurrayK, LucasL, et al.: Association of age, gender, and race with intensity of end-of-life care for Medicare beneficiaries with cancer. J Palliat Med, 2012; 15:548–554.
21.
LoggersET, MaciejewskiPK, PaulkE, et al.: Racial differences in predictors of intensive end-of-life care in patients with advanced cancer. J Clin Oncol, 2009; 27:5559–5564.
22.
MuniS, EngelbergRA, TreecePD, et al.: The influence of race/ethnicity and socioeconomic status on end-of-life care in the ICU. Chest, 2011; 139:1025–1033.
23.
KeatingNL, LandrumMB, LamontEB, et al.: End-of-life care for older cancer patients in the Veterans Health Administration versus the private sector. Cancer, 2010; 116:3732–3739.
24.
WaiteKR, FedermanAD, McCarthyDM, et al.: Literacy and race as risk factors for low rates of advance directives in older adults. J Am Geriatr Soc, 2013; 61:403–406.
25.
ZaideGB, PekmezarisR, NouryanCN, et al.: Ethnicity, race, and advance directives in an inpatient palliative care consultation service. Palliat Support Care, 2013; 11:5–11.
26.
MackJW, PaulkME, KasisomayajulaV, PrigersonHG: Racial disparities in the outcomes of communication on medical care received near death. Arch Intern Med, 2010; 170:1533–1540.
27.
JohnsonKS, KuchibhatlaM, TulskyJA: What explains racial differences in the use of advance directives and attitudes toward hospice care?. J Am Geriatr Soc, 2008; 56:1953–1958.
28.
LoPrestiMA, DementF, GoldFT: End of life care for people with cancer from ethnic minority groups: A systematic review. Am J Hosp Palliat Care, 2014 [Epub ahead of print].
29.
FineMJ, DemakisJG: The Veterans Health administration's promotion of health equity for racial and ethnic minorities. Am J Public Health, 2003; 93:1622–1624.
30.
KizerKW, DudleyRA: Extreme makeover: Transformation of the veterans health care system. Annu Rev Public Health, 2009; 30:313–339.
31.
TrivediAN, GreblaRC, WrightSM, et al.: Despite improved quality of care in the Veterans Affairs health system, racial disparity persists for important clinical outcomes. Health Aff (Millwood), 2011; 30:707–715.
32.
SahaS, FreemanM, ToureJ, et al.: Racial and ethnic disparities in the VA health care system: A systematic review. J Gen Intern Med, 2008; 23:654–671.
33.
ZulligLL, CarpenterWR, Provenzale1DT, et al.: The association of race with timeliness of care and survival among Veterans Affairs health care system patients with late-stage non-small cell lung cancer. Cancer Manage Res, 2013; 5:157–163.
34.
FischerSM, KutnerJS, SauaiaA, et al.: Lack of ethnic differences in end-of-life care in the Veterans Health Administration. Am J Hosp Palliat Care A2007, 24:277–283.
35.
QuinonesA, O'NeilM, SahaS, et al.: Interventions to Improve Minority Health Care and Reduce Racial and Ethnic Disparities. Veterans Health Administration: Washington, D.C, 2011.
36.
BaileyFA, WilliamsBR, WoodbyLL, et al.: Intervention to improve care at life's end in inpatient settings: The BEACON Trial. J Gen Intern Med, 2014; 29:836–843.
37.
National Consensus Project: Clinical Practice Guidelines for Palliative Care. 2004. www.nationalconsensusproject.org (Last accessed October18, 2015).
FayMP, GraubardBI: Small-sample adjustments for Wald-type tests using sandwich estimators. Biometrics, 2001; 57:1198–1206.
40.
ManclLA, DeRouenTA: A covariance estimator for GEE with improved small-sample properties. Biometrics, 2001; 57:126–134.
41.
PanW, WallMM: Small-sample adjustments in using the sandwich variance estimator in generalized estimating equations. Stat Med, 2002; 21:1429–1441.
42.
KauermannG, CarrollRJ: A note on the efficiency of sandwich covariance estimation. J Am Stat Assoc, 2001; 96:1387–1396.
43.
BraunUK, McCulloughLB, BeythRJ, Wet al.: Racial and ethnic differences in the treatment of seriously ill patients: A comparison of African-American, Caucasian and Hispanic veterans. Pain Med, 2005, 6:18–28.
44.
MeghaniSH, ByunE, GallagherRM: Time to take stock: a meta-analysis and systematic review of analgesic treatment disparities for pain in the United States. Pain Med, 2012; 13:150–174.
45.
BurgessDJ, GravelyAA, NelsonDB, et al.: A national study of racial differences in pain screening rates in the VA health care system. Clin J Pain, 2013; 29:118–123.
46.
XuX, ZuoX, WangX, et al.: Do you feel my pain? Racial group membership modulates empathic neural responses. J Neurosci, 2009; 29:8525–8529.
47.
BookerSQ: African Americans' perceptions of pain and pain management: A systematic review. J Transcult Nurs, 2016; 27:73–80.
48.
TanG, JensenMP, ThornbyJ, et al.: Ethnicity, control appraisal, coping, and adjustment to chronic pain among Black and White Americans. Pain Med, 2005; 6:18–28.
49.
WinstonCA, LeshnerP, KramerJ, et al.: Overcoming barriers to access and utilization of hospice and palliative care services in African-American communities. Omega (Westport), 2004; 50:151–163.
50.
AndersonKO, GreenCR, PayneR: Racial and ethnic disparities in pain: Causes and consequences of unequal care. J Pain, 2009; 10:1187–1204.
51.
MackJW: Racial disparities in the outcomes of communication on medical care received near death. Arch Intern Med, 2010; 170:1533–1540.
52.
Institute of Medicine: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, D.C., 2011.
53.
BarnatoAE, BerhaneZ, WeissfeldLA, et al.: Racial variation in end-of-life intensive care use: A race or hospital effect?. Health Serv Res, 2006; 41:2219–2237.
54.
RhodesRL, XuanL. Paulk ME, et al.: An examination of end-of-life care in a safety net hospital system: A decade in review. J Health Care Poor Underserved, 2013; 24:1666–1675.
55.
SudoreRL, KnightSJ, McMahanRD, et al.: A novel website to prepare diverse older adults for decision making and advance care planning: A pilot study. J Pain Symptom Manage, 2014; 47:674–686.
56.
HebertPL, SiskJE, HowellEA: When does a difference become a disparity? Conceptualizing racial and ethnic disparities in health. Health Aff (Millwood), 2008; 27:374–382.
57.
BravemanPA, KumanyikaS, FieldingJ, et al.: Health disparities and health equity: The issue is justice. Am J Public Health, 2011; 101(Suppl 1):S149–S155.
