Disparities in End-of-Life Care: A Perspective and Review of Quality

Abstract

T he elderly constitute an ever-increasing proportion of the US population. There was a 15% increase in the number of people older than age 65 between 2000 and 2010, 1 more than initially predicted by the US Census. 2 The same model forecasts a more than 70% increase in the same cohort over the next 20 years, and a more than 60% increase in those older than age 85. Already health care cost per capita for those older than age 65 is estimated to be 3 to 5 times greater than for those younger than age 65.3 A shift from acute care to chronic disease management and long-term health care modalities is anticipated. Simultaneous to this increase in the elderly population is a marked expansion in medical technology. Testing and procedural intervention are becoming not only more numerous, but far more sophisticated and costly.As the proportion of the elderly population expands and medical technology advances, a rapidly increasing percentage of health care resources is being allocated to care at the end of life (EOL). However, it is unclear whether such resources provide value. In this context, there is a need to understand how such resources are utilized and how utilization decisions are made.Variation in the use of EOL resources and decisions is attributed to patient variables, hospital factors, and the sociocultural platform in which both patient and provider exist. [4][5][6] This article focuses on patient variables and employs a systematic approach to advance our understanding of factors that influence EOL care. In particular, we explore recent findings that minority patients are more likely to receive overtreatment and discuss possible explanations.

Racial and Geographic Disparities in Interhospital ICU Transfers*

“…Second, minority patients and families may be less likely to request or consent to being transferred to large, unfamiliar facilities, and may prefer to receive care from local providers they know and trust. Third, there may be cultural or ethnic differences with respect to preferences that are unrelated to mistrust; studies of end-of-life preferences in chronic obstructive pulmonary disease suggest such differences (6). Fourth, the physicians who treat these patients may be less well-connected with the medical system at large, and therefore less likely to refer patients to external sources of care.…”

Use of Palliative Care in Patients With End-Stage COPD and Receiving Home Oxygen

“…In other populations, low socioeconomic status has been shown to be associated with both higher and lower rates of referral for hospice and palliative care. [15][16][17][18][19] The increased referral to PC seen in larger teaching hospitals likely reflects the presence of subspeciality PC services in these hospitals compared with smaller rural hospitals.…”

Access to Palliative Care for Patients Undergoing Mechanical Ventilation With Idiopathic Pulmonary Fibrosis in the United States

“…13,14 In addition, nonwhite patients have been shown to die with full support and receive overtreatment at the end of life. 15 Our findings of Hispanic race being associated with less referral to PC need to be interpreted with caution. Race information was missing more often in the non-PC arm compared to the PC cohort, which may lead to bias.…”