Racial Differences in Palliative Care Use After Stroke in Majority-White, Minority-Serving, and Racially Integrated U.S. Hospitals

Abstract

Objective Racial/ethnic differences in palliative care resource use after stroke have been recognized, but it is unclear whether patient or hospital characteristics drive this disparity. We sought to determine whether palliative care use after intracerebral hemorrhage (ICH) and ischemic stroke differs between hospitals serving varying proportions of minority patients. Design Population-based cross-sectional study. Setting Inpatient hospital admissions from the Nationwide Inpatient Sample between 2007 and 2011. Patients A total of 46,735 intracerebral hemorrhage and 331,521 ischemic stroke cases. Interventions Palliative care use. Measurements and Main Results Intracerebral hemorrhage and ischemic stroke admissions were identified from the Nationwide Inpatient Sample between 2007 and 2011. Hospitals were categorized based on the percentage of ethnic minority stroke patients (<25% minorities [“white hospitals”], 25–50% minorities [“mixed hospitals”], or >50% minorities [“minority hospitals”]). Logistic regression was used to evaluate the association between race/ethnicity and palliative care use within and between the different hospital strata. Stroke patients receiving care in minority hospitals had lower odds of palliative care compared to those treated in white hospitals, regardless of individual patient race/ethnicity (adjusted odds ratio [OR] 0.65, 95% CI 0.50–0.84 for ICH, and OR 0.62, 95% CI 0.50–0.77 for ischemic stroke). Ethnic minorities had a lower likelihood of receiving palliative care compared to whites in any hospital stratum, but the odds of palliative care for both white and minority ICH patients was lower in minority compared to white hospitals (OR 0.66, 95% CI 0.50–0.87 for white, and OR 0.64, 95% CI 0.46–0.88 for minority patients). Similar results were observed in ischemic stroke. Conclusions The odds of receiving palliative care for both white and minority stroke patients is lower in minority compared to white hospitals, suggesting system-level factors as a major contributor to explain race disparities in palliative care use after stroke.

Timing is everything: Early do-not-resuscitate orders in the intensive care unit and patient outcomes

“…Consistent with the published literature on the subject, [11][12][13] most patients in this cohort had a late DNR. As others have published, older patients, those with more comorbidities, and those who were white were more likely to have an early DNR [4,[28][29][30] Older patients and those with comorbidities may have more opportunity for discussion with their doctors and families about advanced directives and may be more likely to have accepted their own mortality. [31,32] The racial disparity may be, in part, due to distrust of the health care system among patients who are members of racial or ethnic minority groups [33][34][35] who may perceive DNR orders as denying patients life-saving medical care.…”

What do family caregivers know about palliative care? Results from a national survey

“…In our multivariable analysis, palliative care awareness was lower among caregivers who were African-American and who had less than a college education. Studies have consistently observed lower utilization of palliative care services among these demographic groups (Faigle et al, 2017; Johnson, 2013; Rizzuto & Aldridge, 2018) and, when accessed, it is often in the last weeks to days of life (Sharma et al, 2015). Furthermore, African-Americans and other racial minorities and those with less education receive more aggressive curative treatments and intensive hospital-based care at end of life (Barnato et al, 2006, 2009; Brown et al, 2018; Johnson, 2013; Johnson et al, 2008, 2013), which are trends that are less likely when palliative care services are involved earlier in the illness trajectory (Scibetta et al, 2016).…”

Trends and Racial Disparities of Palliative Care Use among Hospitalized Patients with ESKD on Dialysis

“…Hospitals were grouped by the proportion of minority patients admitted during the study time period: high-minority hospitals (.50%), medium-minority hospitals (25%-49%), and low-minority hospitals (,25%). 26…”