Gaps in Provision of Primary and Specialty Palliative Care in the Acute Care Setting by Race and Ethnicity

Abstract

Context Previous research has identified a large unmet need in provision of specialist-level palliative care services in the hospital. How much of this gap is filled by primary palliative care provided by generalists or non-palliative specialists has not been quantified. Estimates of racial and ethnic disparities have been inconsistent. Objectives 1) To estimate primary and specialty palliative care delivery and to measure unmet needs in the inpatient setting and 2) to explore racial and ethnic disparities in palliative care delivery. Methods This was a cross-sectional, retrospective study of 55,658 adult admissions to two acute care hospitals in the Bronx in 2013. Patients with palliative care needs were identified by criteria adapted from the literature. The primary outcomes were delivery of primary and specialist-level palliative care. Results 18.5% of admissions met criteria for needing palliative care. Of those, 18% received specialist-level palliative care, an estimated 30% received primary palliative care, and 37% had no evidence of palliative care or advance care planning. Black and Hispanic patients were not less likely to receive specialist-level palliative care (adjusted OR black patients=1.18, 95% CI 0.98, 1.42; adjusted OR Hispanic patients=1.24, 95% CI 1.04, 1.48), but they were less likely to receive primary palliative care (adjusted OR black patients= 0.41, 95% CI 0.20, 0.84; adjusted OR Hispanic patients=0.48, 95% CI 0.25, 0.94). Conclusions Even when considering primary and specialty palliative care, hospitalized patients have a high prevalence of unmet palliative care need. Further research is needed understand racial and ethnic disparities in palliative care delivery.

Delivery of Palliative Care in Acute Care Hospitals: A Population-Based Retrospective Cohort Study Describing the Level of Involvement and Timing of Inpatient Palliative Care in the Last Year of Life

“…For instance, previous research has reported that between 8% and 26% of hospitalized adults with life-limiting illness or another indication of palliative care needs received an inpatient palliative care consultation, and between 2% and 9% were admitted to a palliative care unit. [5][6][7][8][9][10][11]35 This is in contrast to our results where 35% of hospitalized decedents received inpatient palliative care. These differences may reflect regional variations in palliative care delivery.…”

“…4 Much of the existing literature has evaluated inpatient palliative care as a dichotomy-that is, patients either received or did not receive palliative care, often with a focus on specialist-led care-without recognizing the diversity of approaches through which palliative care may be delivered. [5][6][7][8][9][10][11] We thus have limited understanding of the nuances of inpatient palliative care delivery.…”

Racial Disparities in Utilization of Palliative Care Among Patients Admitted With Advanced Solid Organ Malignancies

“…Perceived time to death or death acting as a mediator on the relationship between race and receipt of IPCC may contribute to the mixed findings of the association between race and IPCC in the literature. [21][22][23][24][25][26] Although several studies have found higher odds of IPCC for hospitalized black patients with cancer, a few have found no difference or higher odds of IPCC for black patients compared to white patients. [21][22][23][24][25][26] However, only one of these studies investigated death as a mediator of receipt of IPCC.…”

“…[17][18][19][20] Furthermore, studies evaluating the use of nonhospice-based palliative care are often limited to a single center, a single type of malignancy, or do not specifically aim to investigate racial disparities in health care. [21][22][23][24][25][26] Black patients have higher rates of emergency department visits, hospitalizations, and intensive care unit care at EOL compared to white patients. 6,27,28 Inpatient palliative care consultations (IPCC) offer a unique opportunity to introduce black patients and their families to non-hospice-based palliative care services as blacks are more likely to be treated at the EOL in an inpatient setting.…”

Race and Ethnicity and Satisfaction With Communication in the Intensive Care Unit

“…In a previous study, we have shown that clinicians are less than half as likely to have an EoL care discussion with black patients with serious illness compared with whites. 10 When these discussions occur, prognostic information is given less often to black patients. 11 This is problematic because discussions including information on expected length of life have been shown to be critical to facilitating hospice enrollment.…”