Racial disparity in end‐of‐life hospitalizations among nursing home residents with dementia

Abstract

Objective Explore within and across nursing home (NH) racial disparities in end‐of‐life (EOL) hospitalizations for residents with Alzheimer's disease or related dementia (ADRD), and examine whether severe cognitive impairment influences these relationships. Design Observational study merging, at the individual level, C2014‐2017 national‐level Minimum Data Set (MDS), Medicare Beneficiary Summary Files (MBSF), and Medicare Provider Analysis and Review (MedPAR). Nursing Home Compare (NHC) was also used. Setting Long‐stay residents who died in a NH or a hospital within 8 days of discharge. Participants Analytical sample included 665,033 decedent residents with ADRD in 14,595 facilities. Main outcomes and measures The outcome was hospitalization within 30 days of death. Key independent variables were race, severe cognitive impairment, and NH‐level proportion of black residents. Other covariates included socio‐demographics, dual eligibility, hospice enrollment, and chronic conditions. Facility‐level characteristics were also included (e.g. profit status, staffing hours, etc.). We fit linear probability models with robust standard errors, fixed and random effects. Results Compared to whites, black decedents had a significantly (p < 0.01) higher risk of EOL hospitalizations (7.88%). Among those with severe cognitive impairment, whites showed a lower risk of hospitalizations (6.04%). But EOL hospitalization risk among blacks with severe cognitive impairment was still significantly elevated (β = 0.0494; p < 0.01). A comparison of the base model with the fixed and random‐effects models showed statistically significant hospitalization risk by decedent's race both within and across facilities. Conclusions and relevance We found disparities between black and white residents with ADRD both within and across facilities. The within‐facility disparities may be due to residents' preferences and/or NH practices that contribute to differential treatment. The across facility differences point to the overall quality of care disparities in homes with a higher prevalence of black residents. Persistence of such systemic disparities among the most vulnerable individuals is extremely troubling.

Association of Medicare Mandatory Bundled Payment Reform With Joint Replacement Surgery Use for Beneficiaries With Alzheimer Disease and Related Dementias

“…Third was a binary indicator of whether or not a beneficiary was ever diagnosed with ADRD. [15][16][17] This indicator was determined by Medicare using ADRD diagnosis codes in multiple claims data sources. In statistical analysis, we included the main effects of these 3 variables along with their 2-way and 3-way interactions.…”

Racial and Ethnic Differences in Hospice Use and Hospitalizations at End-of-Life Among Medicare Beneficiaries With Dementia

“…Furthermore, while studies have examined dementia end-of-life care, the analyses often are restricted to nursing home residents. 14 , 15 , 16 These estimates are limited because they omit a substantial proportion of dementia patients living at home or other settings prior to death. 6 The samples typically lack racial and ethnic diversity, and thus robust data on non-White decedents with dementia are sparse.…”

Quality of Care and Outcomes Among a Diverse Group of Long-Term Care Residents With Alzheimer’s Disease and Related Dementias

“…The present study results extend prior work on racial and ethnic disparities among nursing home residents and people with ADRD (Rivera-Hernandez et al, 2020; Rivera-Hernandez et al, 2018; US Department of Health and Human Services, 2014). Racial and ethnic differences have been documented across the dementia care continuum from detection, diagnosis, and treatment to access to appropriate services (in-home care services or long-term care) and end-of-life care (Chin et al, 2011; Sadarangani et al, 2020; Temkin-Greener et al, 2019; Zuckerman et al, 2008). Others have noted racial/ethnic differences in antidepressant use/prescribing and pain/pain management among nursing home residents (Karkare et al, 2011; Levin et al, 2007; Mack et al, 2018), which may be similar among residents with ADRD.…”