Disparities of Care for African-Americans and Caucasians with Community-Acquired Pneumonia: A Retrospective Cohort Study

Abstract

BackgroundAfrican-Americans admitted to U.S. hospitals with community-acquired pneumonia (CAP) are more likely than Caucasians to experience prolonged hospital length of stay (LOS), possibly due to either differential treatment decisions or patient characteristics.MethodsWe assessed associations between race and outcomes (Intensive Care Unit [ICU] variables, LOS, 30-day mortality) for African-American or Caucasian patients over 65 years hospitalized in the Veterans Health Administration (VHA) with CAP (2002-2007). Patients admitted to the ICU were analyzed separately from those not admitted to the ICU. VHA patients who died within 30 days of discharge were excluded from all LOS analyses. We used chi-square and Fisher's exact statistics to compare dichotomous variables, the Wilcoxon Rank Sum test to compare age by race, and Cox Proportional Hazards Regression to analyze hospital LOS. We used separate generalized linear mixed-effect models, with admitting hospital as a random effect, to examine associations between patient race and the receipt of guideline-concordant antibiotics, ICU admission, use of mechanical ventilation, use of vasopressors, LOS, and 30-day mortality. We defined statistical significance as a two-tailed p ≤ 0.0001.ResultsOf 40,878 patients, African-Americans (n = 4,936) were less likely to be married and more likely to have a substance use disorder, neoplastic disease, renal disease, or diabetes compared to Caucasians. African-Americans and Caucasians were equally likely to receive guideline-concordant antibiotics (92% versus 93%, adjusted OR = 0.99; 95% CI = 0.81 to 1.20) and experienced similar 30-day mortality when treated in medical wards (adjusted OR = 0.98; 95% CI = 0.87 to 1.10). African-Americans had a shorter adjusted hospital LOS (adjusted HR = 0.95; 95% CI = 0.92 to 0.98). When admitted to the ICU, African Americans were as likely as Caucasians to receive guideline-concordant antibiotics (76% versus 78%, adjusted OR = 0.99; 95% CI = 0.81 to 1.20), but experienced lower 30-day mortality (adjusted OR = 0.82; 95% CI = 0.68 to 0.99) and shorter hospital LOS (adjusted HR = 0.84; 95% CI = 0.76 to 0.93).ConclusionsElderly African-American CAP patients experienced a survival advantage (i.e., lower 30-day mortality) in the ICU compared to Caucasians and shorter hospital LOS in both medical wards and ICUs, after adjusting for numerous baseline differences in patient characteristics. There were no racial differences in receipt of guideline-concordant antibiotic therapies.

Satisfaction with care and decision making among parents/caregivers in the pediatric intensive care unit: A comparison between English-speaking whites and Latinos

“…Previous studies of health disparities in the ICU have used concrete and definitive ICU outcome measures such as survival, length of hospitalization, and utilization of resources to assess aspects of health care delivery [7][8][9][10]. If disparities exist in the ICU, they might manifest in more subjective perceptions of treatment in the ICU, rather than objective measures of treatment delivered.…”

“…Shippee et al [6] found that African American adults were less likely than white adults to be admitted to a cardiac care unit when required. In a study of critically ill patients, elderly African American patients who had community-acquired pneumonia had a lower 30-day mortality and shorter hospital length of stay than white patients [7]. Iantorno et al [8] reported no sex-or race-based treatment disparities in the use of pulmonary artery catheterization in the adult ICU population, and Erickson et al [50] did not find any disparities in hospital mortality or ICU length of stay in adult ICU patients.…”

The Effect of Marital Status on the Presentation and Outcomes of Elderly Male Veterans Hospitalized for Pneumonia

“…Baseline patient factors such as age, 6 functional status, 7 and the presence of comorbidities 6 are important determinants of mortality risk. Demographic characteristics such as race 8 and socioeconomic status may be predictors of either short-term or longer-term outcomes, such as length of stay and hospital readmission, although the latter has not been a uniform fi nding. 9 Acute severity of illness, as refl ected by abnormalities in vital signs, gas exchange, and certain laboratory values plays a major role in patient outcomes.…”

Guideline-concordant therapy and outcomes in healthcare-associated pneumonia

“…Patients were elderly (median age 76 yrs) and predominantly consisted of white males (82.1% white, 98.3% males), an innate characteristic of the majority of patients in the VHA [18,19]. Nearly one-quarter of patients (22.6%) had more than one HCAP risk factor on admission.…”