Asian American Medicare Beneficiaries Disproportionately Receive Invasive Mechanical Ventilation When Hospitalized at the End-of-Life

Jia, Z.; Leiter, Richard E.; Sanders, Justin; Sullivan, Donald R.; Gozalo, Pedro; Bunker, Jennifer; Teno, Joan M.

doi:10.1007/s11606-021-06794-6

Cited by 15 publications

(18 citation statements)

References 59 publications

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“…Notwithstanding our findings specific to NHs, our results, including those showing differences in EOL care by race and ethnicity 28 , 29 , 30 or by dual eligibility status, 30 , 35 are consistent with previous studies. These patterns of aggressive EOL care, especially for NH residents, many of whom have a high comorbidity burden, stand in contrast with the increased emphasis over the past decades on reducing aggressive EOL care.…”

Section: Discussionsupporting

confidence: 93%

“…These variables were added as covariates in our multivariable models. Based on prior studies, we hypothesized that being younger, a person from a racial or ethnic minority group, 28 , 29 , 30 or dually enrolled in Medicare and Medicaid 31 would be associated with higher odds of receiving aggressive EOL care and that having a higher comorbidity burden or a cancer with high case-fatality rate (eg, lung or pancreas cancer) would be associated with lower odds of receiving aggressive EOL care. Last, we added the year of death variable to detect potential temporal trends in the implementation of Patient Protection and Affordable Care Act (ACA)–related stipulations to improve EOL care, 32 even if the study years were in the post-ACA era.…”

Section: Methodsmentioning

confidence: 99%

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Incidence of Aggressive End-of-Life Care Among Older Adults With Metastatic Cancer Living in Nursing Homes and Community Settings

Koroukian

Douglas

et al. 2023

JAMA Netw Open

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ImportanceNearly 10% of the 1.5 million persons residing in nursing homes (NHs) have received or will receive a diagnosis of cancer. Although aggressive end-of-life (EOL) care is common among community-dwelling patients with cancer, little is known about such patterns of care among NH residents with cancer.ObjectiveTo compare markers of aggressive EOL care between older adults with metastatic cancer who are NH residents and their community-dwelling counterparts.Design, Setting, and ParticipantsThis cohort study used the Surveillance, Epidemiology, and End Results database linked with the Medicare database and the Minimum Data Set (including NH clinical assessment data) for deaths occurring from January 1, 2013, to December 31, 2017, among 146 329 older patients with metastatic breast, colorectal, lung, pancreas, or prostate cancer, with a lookback period in claims data through July 1, 2012. Statistical analysis was conducted between March 2021 and September 2022.ExposuresNursing home status.Main Outcomes and MeasuresMarkers of aggressive EOL care were cancer-directed treatment, intensive care unit admission, more than 1 emergency department visit or more than 1 hospitalization in the last 30 days of life, hospice enrollment in the last 3 days of life, and in-hospital death.ResultsThe study population included 146 329 patients 66 years of age or older (mean [SD] age, 78.2 [7.3] years; 51.9% men). Aggressive EOL care was more common among NH residents than community-dwelling residents (63.6% vs 58.3%). Nursing home status was associated with 4% higher odds of receiving aggressive EOL care (adjusted odds ratio [aOR], 1.04 [95% CI, 1.02-1.07]), 6% higher odds of more than 1 hospital admission in the last 30 days of life (aOR, 1.06 [95% CI, 1.02-1.10]), and 61% higher odds of dying in the hospital (aOR, 1.61 [95% CI, 1.57-1.65]). Conversely, NH status was associated with lower odds of receiving cancer-directed treatment (aOR, 0.57 [95% CI, 0.55-0.58]), intensive care unit admission (aOR, 0.82 [95% CI, 0.79-0.84]), or enrollment in hospice in the last 3 days of life (aOR, 0.89 [95% CI, 0.86-0.92]).Conclusions and RelevanceDespite increased emphasis to reduce aggressive EOL care in the past several decades, such care remains common among older persons with metastatic cancer and is slightly more prevalent among NH residents than their community-dwelling counterparts. Multilevel interventions to decrease aggressive EOL care should target the main factors associated with its prevalence, including hospital admissions in the last 30 days of life and in-hospital death.

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Section: Discussionsupporting

confidence: 93%

Section: Methodsmentioning

confidence: 99%

Incidence of Aggressive End-of-Life Care Among Older Adults With Metastatic Cancer Living in Nursing Homes and Community Settings

Koroukian

Douglas

et al. 2023

JAMA Netw Open

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“…18,19 Research in Canada and the USA showed an increased rate of invasive ventilation at end-of-life for Asian, Black, and Hispanic decedents as compared to white decedents. [20][21][22][23] Results are conflicting in patients with COVID-19 pneumonia. [24][25][26][27] No studies incorporated adjustment for time-varying severity, meaning that prior observed differences in rates of invasive ventilation by race/ethnicity could be explained by greater time-varying clinical severity.…”

Section: Discussionmentioning

confidence: 99%

“…These studies are limited because none adjusted for time-varying severity, many used decedent cohorts, and none attempted to estimate the impact of differences on outcomes. [18][19][20][21][22][23][24][25][26][27] We performed a retrospective cohort study with adjustment for baseline confounding and time-varying severity to investigate (1) the association between patient race/ethnicity and use of invasive ventilation and (2) the survival effect mediated by differential use of invasive ventilation.…”

Section: Introductionmentioning

confidence: 99%

Association between patient race/ethnicity and invasive ventilation in hypoxemic respiratory failure

Abdelmalek

Angriman

Moore

et al. 2022

Preprint

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Importance: Differential use of therapies for respiratory failure according to patient race/ethnicity may represent health inequity and could impact patient survival. Objective: Measure the association between patient race/ethnicity and the use of invasive ventilation, and the impact of any association on survival. Design: Retrospective cohort analysis using a Bayesian multistate model that adjusted for baseline covariates and time-varying severity. Setting: Multicenter study using the Medical Information Mart for Intensive Care IV (MIMIC-IV) and Phillips eICU (eICU) databases from the USA. Participants: Non-intubated adults receiving oxygen within the first 24 hours of ICU admission. Exposure: Patient race/ethnicity (Asian, Black, Hispanic, white). Main outcomes and measures: Primary output was the cause-specific hazard ratio (HR) of invasive ventilation for patient race/ethnicity. Secondary output was change in 28-day survival mediated by differences in invasive ventilation rate. We reported posterior means and 95% credible intervals (CrI). Results: We studied 38,263 patients, 52% (20,033) from MIMIC-IV and 48% (18,230) from eICU, 2% Asian (892), 11% Black (4,289), 5% Hispanic (1,964), and 81% white (31,923). Invasive ventilation occurred in 3,511 (9.2%), and 2,869 (7.5%) died. The rate of invasive ventilation was lower in Asian (HR 0.82, CrI 0.70 to 0.95), Black (HR 0.78, CrI 0.71 to 0.86), and Hispanic (HR 0.70, CrI 0.61 to 0.79) patients as compared to white patients. For the average patient, lower rates of invasive ventilation did not mediate differences in survival. For a reference patient with inspired oxygen (FiO2) varied from 0.5 to 1.0, the change in survival mediated by lower rates of invasive ventilation ranged from probable benefit (probability 0.82 for Asian patients, 0.91 for Black patients, and 0.93 for Hispanic patients) at FiO2 0.5 to probable harm (probability 0.87 for Asian patients, 0.92 for Black patients, and 0.97 for Hispanic patients) at FiO2 1.0, although the mean absolute changes in mortality were all less than 1.5%. Conclusions: Asian, Black, and Hispanic patients had a lower rate of invasive ventilation than white patients. The changes in 28-day survival mediated by this difference ranged from slight benefit at lower inspired oxygen fractions to slight harm at inspired oxygen fraction of 1.0, and there was no difference in survival for the average patient.

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“…17 Chinese immigrants came to prominence as a rapidly growing group who are less likely to engage in the advance care planning process and more likely to receive aggressive life-sustaining treatments at the end-of-life when compared with non-immigrant Western populations. 3,4,18…”

Section: Introductionmentioning

confidence: 99%

The role of acculturation in the process of advance care planning among Chinese immigrants: A narrative systematic review

et al. 2023

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Background: Acculturation is the process of two different cultures coming into contact. It is unclear how acculturation influences Chinese immigrants’ engagement in advance care planning due to the complexity and multifaceted nature of both acculturation and advance care planning. Aims: To synthesize evidence regarding the role of Chinese immigrants’ acculturation in their engagement in advance care planning. Design: Systematic mixed-method review, registered in PROSPERO (CRD42021231822). Data sources: EMBASE, MEDLINE, Web of Science, and Google Scholar were searched for publications until January 21, 2021. Results: Twenty-one out of 1112 identified articles were included in the analysis. Of those 21 articles, 17 had a qualitative design and 13 originated from the United States. Three of four quantitative studies reported that higher acculturation levels were associated with better knowledge or higher rate of engagement in advance care planning. Analysis of qualitative studies showed that Chinese immigrants’ engagement in advance care planning was associated with their: (1) self-perceived cultural identity (native or non-native); (2) interpretation of filial piety (traditional or modern); and (3) interpretation of autonomy (individual or familial). To facilitate their engagement, Chinese immigrants prefer an implicit approach, non-family-related initiators, contextualization advance care planning in Chinese culture and using Chinese language. Conclusion: Chinese immigrants’ willingness to engage in advance care planning varied with their acculturation level. To engage them in advance care planning, we recommend adapting the introduction of advance care planning to address people’s perceptions of their cultural identity, filial piety, and autonomy, as well as their preference for certain approach, initiator, context, and language.

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Asian American Medicare Beneficiaries Disproportionately Receive Invasive Mechanical Ventilation When Hospitalized at the End-of-Life

Cited by 15 publications

References 59 publications

Incidence of Aggressive End-of-Life Care Among Older Adults With Metastatic Cancer Living in Nursing Homes and Community Settings

Incidence of Aggressive End-of-Life Care Among Older Adults With Metastatic Cancer Living in Nursing Homes and Community Settings

Association between patient race/ethnicity and invasive ventilation in hypoxemic respiratory failure

The role of acculturation in the process of advance care planning among Chinese immigrants: A narrative systematic review

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