Ethnic differences in the place of death of elderly hospice enrollees

Elderly minorities are more likely to die in inpatient settings than their Caucasian counterparts. It is not known whether this difference is due to cultural preferences for place of death or decreased access to hospice. This analysis examines ethnic differences in the place of death of elderly hospice patients. Using data from a large, national hospice provider, elderly (> or = 65) African-American, Hispanic, and Caucasian decedents admitted to hospice between January 1, 2000, and December 31, 2003, were identified. Of the 115,854 eligible decedents, 78.3% were Caucasian, 10.7% African American, and 11% Hispanic. Hispanics and African Americans were more likely to die in inpatient hospice settings than Caucasians (38.5%, 38.5%, and 32%, respectively). After adjustment for demographic and hospice use variables, older African Americans had higher odds than older Caucasians of dying in an inpatient hospice setting than a nursing home (odds ratio (OR)=1.12, 95% confidence interval (CI)=1.07-1.19). However, African-American ethnicity was not a significant predictor of death in an inpatient setting versus home (OR=1.03, 95% CI=0.97-1.08)). Hispanics had lower odds than Caucasians of death in an inpatient hospice setting than at home (OR=0.88, 95% CI=0.84, 0.93) and higher odds of death in an inpatient setting than a nursing home (OR=1.45, 95% CI=1.37-1.53). Admission to hospice reduces but does not eliminate ethnic differences in place of death. Further research should examine the effect of individual and cultural preferences for place of death on decisions to enroll in hospice.     

Racial differences in hospice revocation to pursue aggressive care

BACKGROUND: Hospice provides supportive care to terminally ill patients at the end of life. However, some enrollees leave hospice before death in search of therapies that may prolong survival. Because of a greater preference for life-sustaining therapies at the end of life, African American patients may be more likely than white patients to withdraw from hospice to seek life-prolonging therapies. METHODS: In a secondary data analysis of African American and white patients discharged from VITAS hospice programs between January 1, 1999, and December 31, 2003, we used logistic regression to examine the association between race and discharge disposition defined as hospice revocation to pursue aggressive care (eg, emergency medical care, chemotherapy, or invasive medical intervention) vs all other discharges. We used a Cox proportional hazards model to examine survival at 1 year after hospice revocation in a subgroup of enrollees from Florida hospice programs. RESULTS: Of the 166 197 enrollees, 2.8% revoked hospice to pursue aggressive care, and African American patients were more likely than white patients to do so (4.5% vs 2.5%; P< .001). In multivariate analysis, African American patients had a 70% higher odds of leaving hospice to pursue life-prolonging therapies (odds ratio, 1.70; 95% confidence interval, 1.57-1.84). In the subgroup analysis, 48.4% of the enrollees who revoked hospice to pursue life-prolonging therapies were still alive at 1 year. CONCLUSIONS: African American patients were more likely than white patients to revoke hospice to pursue life-prolonging therapies. Models of health care that couple curative and palliative therapies may be more attractive to African American patients and more effective at maximizing continuity throughout life-limiting illness.     

What Explains Racial Differences in the Use of Advance Directives and Attitudes Toward Hospice Care?

Cultural beliefs and values are thought to account for differences between African Americans and whites in the use of advance directives and beliefs about hospice care, but few data clarify which beliefs and values explain these differences. Two hundred five adults aged 65 and older who received primary care in the Duke University Health System were surveyed. The survey included five scales: Hospice Beliefs and Attitudes, Preferences for Care, Spirituality, Healthcare System Distrust, and Beliefs About Dying and Advance Care Planning. African Americans were less likely than white subjects to have completed an advance directive (35.5% vs 67.4%, P<.001) and had less favorable beliefs about hospice care (Hospice Beliefs and Attitudes Scale score, P<.001). African Americans were more likely to express discomfort discussing death, want aggressive care at the end of life, have spiritual beliefs that conflict with the goals of palliative care, and distrust the healthcare system. In multivariate analyses, none of these factors alone completely explained racial differences in possession of an advance directive or beliefs about hospice care, but when all of these factors were combined, race was no longer a significant predictor of either of the two outcomes. These findings suggest that ethnicity is a marker of common cultural beliefs and values that, in combination, influence decision-making at the end of life. This study has implications for the design of healthcare delivery models and programs that provide culturally sensitive end-of-life care to a growing population of ethnically diverse older adults.     

Hospice usage by minorities in the last year of life: results from the National Mortality Followback Survey

OBJECTIVES: To examine racial/ethnic variations in rates of hospice use in a national cohort and to identify individual characteristics associated with hospice use. DESIGN: Secondary analysis of the 1993 National Mortality Followback Survey (NMFS), a nationally obtained sample using death certificates and interviews with relatives (proxy respondents) to provide mortality, social, and economic data and information about healthcare utilization in the last year of life for 23,000 deceased individuals. SETTING: Hospice care. PARTICIPANTS: Individuals aged 15 and older who died in 1993. Subjects were included in this analysis if they died of nontraumatic causes (N = 11,291). MEASUREMENTS: Hospice use was dichotomized by proxy responses indicating use or nonuse of home or inpatient hospice services. The percentage of individuals using hospice services in the last year of life was calculated. RESULTS: Unadjusted bivariate results found that African Americans were less likely to use hospice than whites (odds ratio (OR) = 0.59; P <.001) and that those without a living will (LW) (OR = 0.23; P <.001) and without a cancer diagnosis (OR = 0.28; P <.001) were less likely to use hospice. The negative relationship between African Americans and hospice use was unaffected when controlled for sex, education, marital status, existence of a LW, income, and access to health care. Logistic models revealed that presence of a LW diminished the negative relationship between African Americans and hospice use, but the latter remained significant (OR = 0.83; P =.033). A subanalysis of subjects aged 55 and older showed a significant interaction between access to care and race/ethnicity with respect to hospice use (P =.044). Inclusion of income in this multivariable logistic model attenuated the relationship between African-American race/ethnicity and hospice use (OR = 0.77), and the difference between whites and African Americans became only marginally statistically significant (P =.060). CONCLUSION: In the 1993 NMFS, hospice use was negatively associated with African-American race/ethnicity independent of income and access to healthcare. The relationship is not independent of age, insurance type, or history of stroke. For subjects aged 55 and older, access to healthcare may be an important confounder of the negative relationship between African-American race/ethnicity and hospice use. Consistent with previous studies, this analysis found that African Americans were less likely to use LWs than whites. The reduced importance of African-American race/ethnicity on hospice use with the inclusion of presence of a LW in logistic models suggests that similar cultural processes may shape differences between African Americans and whites in advance care planning and hospice use.     

Older Asian Americans and Pacific Islanders dying of cancer use hospice less frequently than older white patients

PURPOSE: Cancer is the leading cause of death among Asian Americans, yet little is known about their use of hospice care. We examined hospice use by Asian patients compared with white patients, and assessed whether utilization differs among those born in the United States or abroad. METHODS: We studied Asian and white Medicare beneficiaries registered in the Surveillance, Epidemiology, and End Results (SEER) Program who died of primary lung, colorectal, prostate, breast, gastric, or liver cancer between 1988 and 1998. We used logistic regression to determine the effects of race/ethnicity and birthplace on hospice use, adjusting for demographic characteristics, managed care insurance, year of diagnosis, tumor stage at diagnosis, and tumor registry. RESULTS: Of the 184,081 patients, 5% (n = 8614) were Asian Americans, of whom 45% (n = 3847) were foreign born. Compared with whites, Asian Americans were more likely to be male, married, and enrolled in managed care. Compared with U.S.-born Asian Americans, foreign-born Asian Americans were more likely to reside in low-income areas. After adjustment, patients who were Asian American (odds ratio [OR] = 0.67; 95% confidence interval [CI]: 0.62 to 0.73) and born abroad (OR = 0.90; 95% CI: 0.86 to 0.94) were less likely to use hospice care than were white patients. These results were consistent across the six cancer diagnoses that were examined. CONCLUSION: Older Asian Americans dying of cancer, especially those who are born abroad, are less likely than white patients to use hospice care at the end of life. Additional research is needed to understand the reasons for these differences and to eliminate potential barriers to hospice care.     

Comparison of data quality for reports and ratings of ambulatory care by African American and White Medicare managed care enrollees

OBJECTIVE: Compare missing data and reliability of health care evaluations between African Americans and Whites in Medicare managed care health plans. METHOD: Consumer Assessment of Healthcare Providers and Systems (CAHPS) 3.0 health plan survey data collected from 109,980 Medicare managed care enrollees (101,189 Whites, 8,791 African Americans) in 321 plans. Participants self-administered the survey and four single-item global ratings of care. RESULTS: Missing data rates were significantly higher for African Americans than Whites on all CAHPS items (p < .0001). Internal consistency reliability estimates for the CAHPS scales did not differ significantly between African Americans and Whites, but plan-level reliability estimates for the scales and global rating items were significantly lower for African Americans than Whites. DISCUSSION: Higher missing data rates and lower plan-level reliability estimates for African American Medicare managed care enrollees suggest caution in making race/ethnicity comparisons. Future efforts are needed to enhance the quality of data collected from older African Americans.     

Ethnic disparities in hospice use among Asian-American and Pacific Islander patients dying with cancer

Asian Americans and Pacific Islanders (AAPIs) are a rapidly growing population in the United States, yet little is known about hospice use and length of stay in hospice of older AAPIs dying with cancer. A retrospective study was conducted of the last year of life of AAPI and white Medicare beneficiaries registered in the Surveillance, Epidemiology, and End Results Program. White (n=175,467) and AAPI (n=8,614) patients aged 65 and older who were dying with lung, colorectal, breast, prostate, gastric, or liver cancer were studied. Cox proportional hazards models were used to examine hospice use and length of stay in hospice. All AAPI subgroups studied had lower rates of hospice use (Chinese (adjusted hazard ratio (HR)=0.62, 95% confidence interval (CI)=0.55–0.69), Japanese (adjusted HR=0.67, 95% CI=0.60–0.73), Filipino (adjusted HR=0.61, 95% CI=0.54–0.70), Hawaiian/Pacific Islanders (adjusted HR=0.78, 95% CI=0.67–0.91), and other Asians (adjusted HR=0.70), 95% CI=0.55–0.90) than white patients, adjusting for patient demographic and clinical characteristics. Of those who enrolled in hospice (approximately 20% of the total sample), Japanese Americans had a shorter median length of stay (21 days), and Filipino Americans had a longer median length of stay (32 days) than white patients (26 days). Overall, approximately 20% of patients enrolled within 7 days of death, and only 6% had hospice stays that were longer than 2 months, with no significant differences across racial or ethnic groups. In conclusion, in every ethnic subgroup studied, AAPIs were less likely than whites to enroll in hospice. Further research is needed to understand these differences and eliminate potential barriers to hospice care.     

Government expenditures at the end of life for short- and long-stay nursing home residents: differences by hospice enrollment status

OBJECTIVES: To examine end-of-life government expenditures for short- and long-stay Medicare- and Medicaid-eligible (dual-eligible) nursing home (NH) hospice and nonhospice residents. DESIGN: A retrospective cohort study. SETTING: Six hundred fifty-seven Florida NHs. PARTICIPANTS: Dual-eligible NH residents who died in Florida NHs between July and December 1999 (N=5,774). MEASUREMENTS: Nursing home stays of 90 days or less were considered short stays (n=1,739), and those over 90 days were long stays (n=4,035). Three diagnosis groups were studied: cancer without Alzheimer's disease or dementia, Alzheimer's disease or dementia, and other diagnoses. Eligibility and expenditure claims data for 1998 and 1999 were merged with vital statistics and NH resident assessment data to determine diagnoses, location of death, hospice enrollment, eligibility, and expenditures. RESULTS: Twenty percent of short-stay (n=350) and 26% of long-stay (n=958) NH decedents elected hospice; of these, 73% of short-stay and 58% of long-stay NH residents had hospice stays of 30 days or less. Overall, mean government expenditures in the last month of life were significantly less for hospice than nonhospice residents (7,365 dollars; 95% confidence interval (CI)=7,144-7586 dollars vs 8,134 dollars; 95% CI=7,896-8,372 dollars), but 1-month expenditures were only significantly lower for hospice residents with short NH stays, not for those with long NH stays. CONCLUSION: Overall, hospice care in NHs does not appear to increase government expenditures. Because significantly lower expenditures are observed for short-stay NH hospice residents, policy restricting access to Medicare hospice for Medicare skilled nursing facility residents may represent a missed opportunity for savings.     

What is the Business Case for Improving Care for Patients with Complex Conditions?

Background Although hospice care can alleviate suffering at the end of life for patients with cancer, it remains underutilized, particularly by African Americans and Hispanics. Objective To examine whether the racial composition of the census tract where an individual resides is associated with hospice use. Design Retrospective analysis of the Surveillance, Epidemiology, and End Results–Medicare file for individuals dying from breast, colorectal, lung, or prostate cancer (n = 70,669). Measurements Hospice use during the 12 months before death. Results Hospice was most commonly used by individuals who lived in areas with fewer African-American and Hispanic residents (47%), and was least commonly used by individuals who lived in areas with a high percentage of African-American and Hispanic residents (35%). Hispanics (odds ratio 0.51, 95% confidence interval 0.29–0.91) and African Americans (0.56, 0.44–0.71) were less likely to use hospice if they lived in a census tract with a high percentage of both African Americans and Hispanics than if they lived in a low minority tract. African Americans and whites were less likely to receive hospice care if they lived in a census tract with a high percentage of Hispanics than if they lived in a low minority area. Conclusions Increasing hospice use may require interventions to improve the delivery of hospice care in minority communities.     

Barriers to eligibility and enrollment among older women in a clinical trial on osteoporosis: effects of ethnicity and SES

OBJECTIVES: The study examined whether ethnicity or socioeconomic status influenced a group's ability to meet eligibility criteria and willingness to enroll. METHOD: The eligibility and enrollment status of 904 women aged 65 years and older who responded to recruitment efforts of an estrogen and osteoporosis clinical trial were analyzed. RESULTS: Among women screened, 59% were White, 27% African Americans, and 14% Hispanics; average age was 75 years; 57.6% were eligible, of which 32% enrolled. High-income area residents were more likely to be eligible than low-income residents. African Americans were less likely to be eligible for medical reasons than non-African Americans. Eligible Hispanics were more likely to be enrolled than non-Hispanics. African Americans were equally willing to enroll as Whites. Minority residents of low-income areas were more likely to enroll than minority residents of high-income areas. DISCUSSION: Recruitment efforts should address barriers to eligibility and barriers to willingness to enroll.     

Memory complaint as a predictor of cognitive decline: a comparison of African American and White elders

Of a representative, racially mixed community sample of older adults in North Carolina, 59% of Whites and 49% of African Americans reported worsening memory. The complaint about memory was positively correlated with age, depressive symptomatology, and physical function but not with level of cognitive function as measured by the Short Portable Mental Status Questionnaire (SPMSQ) at baseline. In a controlled analysis of longitudinal data, initial SPMSQ score, age, African American race, lower education, depressive symptomatology, and physical deficits at baseline, but not memory complaint, predicted a decline in cognitive function as measured by the SPMSQ 3 years later. Whereas African Americans were less likely to complain of deterioration in memory, actual decline as measured by the SPMSQ was greater for African Americans than for Whites.     

Racial differences in hospice use and in-hospital death among Medicare and Medicaid dual-eligible nursing home residents

PURPOSE: We investigated the role of race in predicting the likelihood of using hospice and dying in a hosptial among dual-eligible (Medicare and Medicaid) nursing home residents. DESIGN AND METHODS: This follow-back cohort study examined factors associated with hospice use and in-hospital death among non-Hispanic Black and non-Hispanic White dual-eligible nursing home residents (N = 30,765) who died in Florida during one of three years: 2000, 2001, or 2002. We used logistic regression models to identify independent predictors of hospice use and in-hospital death. RESULTS: After we controlled for other factors, Black residents were significantly less likely to use hospice and more likely to die in a hospital. Principal cause of death moderated the relationship between race and hospice use: Black residents were significantly less likely to use hospice than White residents among residents without cancer as principal cause of death, but there was no difference among residents with cancer as cause of death. Further analyses for each racial group revealed that the impact of cause of death in predicting hospice use was greater among Black residents than White residents. IMPLICATIONS: Hospice care offers many benefits, including reduced risk of in-hospital death, but Black nursing home residents are less likely to use hospice and may have different perceptions of need for hospice care compared with White residents. Future research and outreach efforts should focus on developing culturally sensitive, disease-focused end-of-life education and communication interventions that target residents, families, nursing home providers, and physicians.     

Managed care,hospice use,site of death,and medical expenditures in the last year of life

BACKGROUND: We examined deaths of Medicare beneficiaries in Massachusetts and California to evaluate the effect of managed care on the use of hospice and site of death and to determine how hospice affects the expenditures for the last year of life. METHODS: Medicare data for beneficiaries in Massachusetts (n = 37 933) and California (n = 27 685) who died in 1996 were merged with each state's death certificate files to determine site and cause of death. Expenditure data were Health Care Financing Administration payments and were divided into 30-day periods from the date of death back 12 months. RESULTS: In Massachusetts, only 7% of decedents were enrolled in managed care organizations (MCOs); in California, 28%. More than 60% of hospice users had cancer. Hospice use was much lower in Massachusetts than in California (12% vs 18%). In both states, decedents enrolled in MCOs used hospice care much more than those enrolled in fee-for-service plans (17% vs 11% in Massachusetts and 25% vs 15% in California). This pattern persisted for those with cancer and younger (aged 65-74 years) decedents. Decedents receiving hospice care were significantly (P<.001 for both) less likely to die in the hospital (11% vs 43% in Massachusetts and 5% vs 43% in California). Enrollment in MCOs did not affect the proportion of in-hospital deaths (those enrolled in fee-for-service plans vs MCOs: 40% vs 39% in Massachusetts; and 37% vs 34% in California). Expenditures in the last year of life were $28 588 in Massachusetts and $27 814 in California; about one third of the expenditures occurred in the last month before death. Hospital services accounted for more than 50% of all expenditures in both states, despite 77% of decedents being hospitalized in Massachusetts and just 55% being hospitalized in California. Among patients with cancer, expenditures were 13% to 20% lower for those in hospice. CONCLUSIONS: Medicare-insured decedents in California were more than 4 times more likely to be enrolled in MCOs, were 50% more likely to use a hospice, and had a 30% lower hospitalization rate than decedents in Massachusetts, yet there are few differences in out-of-hospital deaths or expenditures in the last year of life. However, patients with cancer using hospice did have significant savings.     

Decisions for hospice care in patients with advanced cancer

OBJECTIVES: To identify factors that may influence the decision of whether to enter a hospice program or to continue with a traditional hospital approach in patients with advanced cancer and to understand their decision-making process. DESIGN: Cross-sectional structured interview. SETTING: One community-based hospice and three university-based teaching hospitals. PARTICIPANTS: Two hundred thirty-four adult patients diagnosed with advanced lung, breast, prostate, or colon cancer with a life expectancy of less than 1 year: 173 hospice patients and 61 nonhospice patients receiving traditional hospital care. MEASUREMENTS: Hospice and nonhospice patients' demographic, clinical, and other patient-related characteristics were compared. Multivariate analysis was then conducted to identify variables associated with the hospice care decision in a logistic regression model. Information sources regarding hospice care and people involved in the hospice decision were identified. RESULTS: Patients receiving hospice care were significantly older (average age 69 vs 65 years, P =.009) and less educated (average 11.9 vs 12.9 years, P =.031) and had more people in their households (average 1.66 vs 1.16 persons, P =.019). Hospice patients had more comorbid conditions (1.30 vs 0.93, P =.035) and worse activities of daily living scores (7.01 vs 6.23, P =.030) than nonhospice patients. Hospice patients were more realistic about their disease course than their nonhospice counterparts. Patients' understanding of their prognoses affected their perceptions of the course of their disease. Hospice patients preferred quality of life to length of life. In the multivariate analysis, lower education level and greater number of people in the household were associated with the decision to enter hospice. A healthcare provider first told most of those who entered hospice about hospice. Families largely made the final decision to enter hospice (42%), followed by patients themselves (28%) and physicians (27%). CONCLUSION: The decision to enter hospice is related to demographic, clinical, and other patient-related characteristics. This study suggests that the decision-making process for hospice care in patients with advanced cancer is multidimensional. The healthcare community may better meet the end-of-life care needs of advanced cancer patients through enhanced communication with patients and families, including providing accurate prognoses and better understanding of patients' preferences and values.     

Racial and geographic variations in colectomy rates among hospitalized ulcerative colitis patients.

BACKGROUND & AIMS: Ulcerative colitis is a debilitating disease for which colectomy is curative. Racial disparities have been described for a wide spectrum of surgical procedures. The goal of this study was to characterize racial and geographic differences in colectomy rates among hospitalized ulcerative colitis (UC) patients. METHODS: We analyzed discharge records from the Nationwide Inpatient Sample, the largest representative sample of acute care hospitals throughout the United States. A total of 23,389 discharges with UC from 1998-2003 were included for analysis. Colectomy rates, in-hospital mortality, and length of stay were calculated for non-Hispanic whites, African Americans, and Hispanics. RESULTS: After adjustment for age, gender, health insurance, comorbidity, and hospital characteristics, the colectomy rate ratios for African Americans and Hispanics compared with whites were 0.46 (95% confidence interval, 0.35-0.60) and 0.74 (95% confidence interval, 0.59-0.93), respectively. African Americans experienced a longer interval between admission and colectomy than whites (8.8 vs 5.6 days, P=.02). There were also significant geographic variations in colectomy, with the West and Midwest regions yielding rates 3-fold higher than the Northeast. Although adjusted in-hospital mortality did not differ by race, Medicaid patients had 3.3-fold higher mortality than those with private insurance. Between 1998 and 2003, the colectomy rate decreased among whites but not African Americans and Hispanics. A temporal narrowing of geographic variation in colectomy was also observed. CONCLUSIONS: The rate of colectomy among hospitalized UC patients varies significantly by race and geographic location. Further studies are needed to elucidate the social and biologic underpinnings of these variations.     

Colorectal cancer in African Americans

Colorectal cancer in African Americans has an increased incidence and mortality relative to Whites. The mean age of CRC development in African Americans is younger than that of Whites. There is also evidence for a more proximal colonic distribution of cancers and adenomas in African Americans. African Americans are less likely to have undergone diagnostic testing and screening for colorectal cancer. Special efforts are needed to improve colorectal cancer screening participation rates in African Americans. Clinical gastroenterologists should play an active role in educating the public and primary care physicians about special issues surrounding colorectal cancer in African Americans. Community healthcare groups and gastrointestinal specialists should develop culturally sensitive health education programs for African Americans regarding colorectal cancer. The high incidence and younger age at presentation of colorectal cancer in African Americans warrant initiation of colorectal cancer screening at the age 45 yr rather than 50 yr.     

HIV Risks and Seroprevalence Among Mexican American Injection Drug Users in California

Latinos in the United States are an ethnically diverse group disproportionately affected by HIV/AIDS. We describe HIV seroprevalence, HIV risk behaviors and utilization of health services among Mexican American injection drug users (IDUs) in California (n = 286) and compare them to White (n = 830) and African American (n = 314) IDUs. Study participants were recruited from syringe exchange programs (n = 24) in California. HIV seroprevalence among Mexican Americans (0.5%) was dramatically lower than Whites (5%) and African Americans (8%). Mexican Americans reported fewer sex-related risks than Whites and African Americans though injection-related risks remained high. Compared to Whites, Mexican Americans were more likely to participate in drug treatment during a 6 month period (AOR 1.5, 95% CI 1.1, 2.0) but less likely to receive any health care (AOR 0.6, 95% CI 0.5, 0.8). Exploring cultural and structural factors among Mexican American IDUs may offer new insights into how to maintain low rates of HIV seroprevalence and reduce barriers to health care utilization.     

Willingness to participate in clinical treatment research among older African Americans and Whites

PURPOSE: Using a health services utilization conceptual framework, the purpose of this analysis was to examine race differences in factors predictive of the behavioral intention of older persons to participate in a clinical treatment trial should they have a diagnosis of cancer. In addition, the analysis sought to determine if older African Americans were less likely than Whites to express willingness to participate, given knowledge of the Tuskegee syphilis study and greater fatalistic cancer beliefs. DESIGN AND METHODS: Data were drawn from a community-based telephone survey of 216 African Americans and 222 Whites, 50 years of age and older. RESULTS: Findings show that willingness to participate was significantly higher among males, persons of younger age, higher incomes, and with nonfatalistic cancer beliefs. Race differences were only apparent for the two significant interactions of race with age and high income. Neither knowledge of the Tuskegee study nor fatalistic cancer beliefs were more important for African Americans than for Whites. IMPLICATIONS: Study findings suggest that recruitment strategies need to be tailored to racial differences in factors affecting willingness to participate, particularly those related to age and income level.     

Congestive heart failure hospitalizations and survival in California: patterns according to race/ethnicity

BACKGROUND: Congestive heart failure (CHF) disproportionately affects African Americans, but data are limited concerning CHF hospitalization patterns among Hispanic and Asian populations, the 2 fastest growing ethnic groups in the United States, and race/ethnic patterns of rehospitalization and survival among patients with CHF are unknown. We conducted a study to assess rates of CHF hospitalization, readmission, and survival among diverse populations in California. METHODS AND RESULTS: We used 2 study designs. First, we calculated the population-based incidence of CHF hospitalization in California in 1991. Next we conducted a retrospective cohort study that identified patients initially hospitalized for CHF in 1991 or 1992 and followed these patients for 12 months after their index hospitalization to determine their likelihood of rehospitalization or death. Data were analyzed with Cox proportional hazards models. African Americans had the highest rate of CHF hospitalization. Age-adjusted hospitalization rates were comparable among whites, Latinos, and Asian women and all lower than those in African American, whereas Asian men had the lowest rates. On adjusted analyses, African Americans were more likely than whites and Asians to be rehospitalized (relative risk 1.07; 95% confidence interval 1.04 to 1.10). However, they were less likely to die within the 12-month follow-up period (relative risk 0.86; 95% confidence interval 0.82 to 0.90). Whites, conversely, had the highest posthospitalization mortality rates. CONCLUSIONS: These findings demonstrate important racial-ethnic differences in CHF morbidity and mortality rates. The disparate findings of higher hospitalization and rehospitalization rates and lower mortality rates among African Americans than whites may represent differences in the underlying pathophysiology of CHF in these groups or differences in access to quality care. Further studies are needed to explain these seemingly paradoxical outcomes.     

Does hospice have a role in nursing home care at the end of life?

OBJECTIVES: To assess the possible benefits and challenges of hospice involvement in nursing home care by comparing the survival and needs for palliative care of hospice patients in long-term care facilities with those living in the community. DESIGN: Retrospective review of computerized clinical care records. SETTING: A metropolitan nonprofit hospice. PARTICIPANTS: The records of 1,692 patients were searched, and 1,142 patients age 65 and older were identified. Of these, 167 lived in nursing homes and 975 lived in the community. MEASUREMENTS: Patient characteristics, needs for palliative care, and survival. RESULTS: At the time of enrollment, nursing home residents were more likely to have a Do Not Resuscitate order (90% vs 73%; P < .001) and a durable power of attorney for health care (22% vs 10%; P < .001) than were those living in the community. Nursing home residents also had different admitting diagnoses, most notably a lower prevalence of cancer (44% vs 74%; P < .032). Several needs for palliative care were less common among nursing home residents, including constipation (1% vs 5%; P = .02), pain (25% vs 41%; P < .001), and anticipatory grief (1% vs 9%; P < .001). Overall, nursing home residents had fewer needs for care (median 0, range 0-3 vs median 1, range 0-5; rank sum test P < .001). Nursing home residents had a significantly shorter survival (median 11 vs 19 days; log rank test of survivor functions P < .001) and were less likely to withdraw from hospice voluntarily (8% vs 14%; P = .03). However, there was no difference in the likelihood of becoming ineligible during hospice enrollment (6% for both groups). CONCLUSIONS: These results suggest that hospices identify needs for palliative care in a substantial proportion of nursing home residents who are referred to hospice, although nursing home residents may have fewer identifiable needs for care than do community-dwelling older people. However, the finding that nursing home residents' survival is shorter may be of concern to hospices that are considering partnerships with nursing homes. An increased emphasis on hospice care in nursing homes should be accompanied by targeted educational efforts to encourage early referral.