Advance Care Planning and Treatment Intensity Before Death Among Black,Hispanic, and White Patients Hospitalized with COVID-19 |
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| Authors: | Amber E Barnato Gregory R Johnson John D Birkmeyer Jonathan S Skinner Allistair James O&#x;Malley Nancy J O Birkmeyer |
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| Institution: | 1.The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH USA ;2.Department of Medicine, Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, NH USA ;3.Sound Physicians, Tacoma, WA USA ;4.Department of Economics, Dartmouth College, Hanover, NH USA ;5.Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH USA |
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| Abstract: | BackgroundBlack and Hispanic people are more likely to contract COVID-19, require hospitalization, and die than White people due to differences in exposures, comorbidity risk, and healthcare access.ObjectiveTo examine the association of race and ethnicity with treatment decisions and intensity for patients hospitalized for COVID-19.DesignRetrospective cohort analysis of manually abstracted electronic medical records.Patients7,997 patients (62% non-Hispanic White, 16% non-Black Hispanic, and 23% Black) hospitalized for COVID-19 at 135 community hospitals between March and June 2020Main MeasuresAdvance care planning (ACP), do not resuscitate (DNR) orders, intensive care unit (ICU) admission, mechanical ventilation (MV), and in-hospital mortality. Among decedents, we classified the mode of death based on treatment intensity and code status as treatment limitation (no MV/DNR), treatment withdrawal (MV/DNR), maximal life support (MV/no DNR), or other (no MV/no DNR).Key ResultsAdjusted in-hospital mortality was similar between White (8%) and Black patients (9%, OR=1.1, 95% CI=0.9–1.4, p=0.254), and lower among Hispanic patients (6%, OR=0.7, 95% CI=0.6–1.0, p=0.032). Black and Hispanic patients were significantly more likely to be treated in the ICU (White 23%, Hispanic 27%, Black 28%) and to receive mechanical ventilation (White 12%, Hispanic 17%, Black 16%). The groups had similar rates of ACP (White 12%, Hispanic 12%, Black 11%), but Black and Hispanic patients were less likely to have a DNR order (White 13%, Hispanic 8%, Black 7%). Among decedents, there were significant differences in mode of death by race/ethnicity (treatment limitation: White 39%, Hispanic 17% (p=0.001), Black 18% (p<0.0001); treatment withdrawal: White 26%, Hispanic 43% (p=0.002), Black 28% (p=0.542); and maximal life support: White 21%, Hispanic 26% (p=0.308), Black 36% (p<0.0001)).ConclusionsHospitalized Black and Hispanic COVID-19 patients received greater treatment intensity than White patients. This may have simultaneously mitigated disparities in in-hospital mortality while increasing burdensome treatment near death.KEY WORDS: COVID-19, racial disparities, terminal care, mortality, intensive care unit, mechanical ventilation, do not resuscitate order, advance care planning, hospital medicine, medical decision-making |
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