Trends in Engagement in Advance Care Planning Behaviors and the Role of Socioeconomic Status

Context: Completion of advance directives (ADs) enhances the likelihood of receiving goal-concordant treatments near the end of life. Previous research on community samples have shown that completion of ADs is less common in lower socioeconomic status demographic group; there is a paucity of such research in patients with cancer. Objectives: To study the effect of income and education on the completion of ADs. Hypothesis: Patients with cancer having lower incomes and education levels would be less likely to report completing ADs. Methods: We conducted cross-sectional analyses of data provided by patients (n = 265) enrolled in the Values and Options in Cancer Care clinical trial. Patients with advanced cancer reported whether they had (1) completed a living will or (2) designated a health-care proxy. Response options for both questions were yes (scored 1), no (scored 0), and unsure (scored 0). We studied the association of lower household income (≤US$20 000) and education level (never attended college) with AD scores. Results: Patients with lower annual incomes had lower AD scores (estimate −0.44; confidence intervals [CI]: −0.71 to −0.16, P = .001); the association between higher educational attainment (some college or more) and completion of ADs was not statistically significant (estimate 0.04, CI: −0.16 to 0.24, P = .70). Conclusion: Interventions to promote completion of ADs among lower income patients with serious illnesses are needed.

Section: Discussionmentioning

confidence: 75%

Is Annual Income a Predictor of Completion of Advance Directives (ADs) in Patients With Cancer

Saeed

Xing

Tancredi

et al. 2018

“…14 However, other work that used education and income as proxies for SES and examined the trends over time demonstrated that SES had a limited role in advance care planning although those with a higher SES were more likely to have a designated power of attorney. 15 Deborah Carr’s work examined assets, occupation, and education and found that although all of these SES measures were associated with rates of advance care planning (as SES increased, ACP increased), assets were the most powerful predictor. Assets also demonstrated a graded association with increased ACP as assets increased, a relationship not seen with education and occupation.…”

Section: Discussionmentioning

confidence: 99%

“…14 Khosla’s longitudinal study that used income and education as predictors of ACP did not support these findings. 15…”

Section: Introductionmentioning

confidence: 99%

An Individual Housing-Based Socioeconomic Status Measure Predicts Advance Care Planning and Nursing Home Utilization

Barwise

Juhn

et al. 2018

Background: Socioeconomic status (SES) is an important determinant of disparities in health care and may play a role in end-of-life care and decision-making. The SES is difficult to retrospectively abstract from current electronic medical records and data sets. Objective: Using a validated SES measuring tool derived from home address, the HOUsing-based SocioEconomic Status index, termed HOUSES we wanted to determine whether SES is associated with differences in end-of-life care and decision-making. Design/Setting/Participants: This cross-sectional study utilized a cohort of Olmsted County adult residents admitted to 7 intensive care units (ICUs) at Mayo Rochester between June 1, 2011, and May 31, 2014. Measurements: Multiple variables that reflect decision-making and care at end of life and during critical illness were evaluated, including presence of advance directives and discharge disposition. The SES was measured by individual housing-based SES index (HOUSES index; a composite index derived from real property as a standardized z-score) at the date of admission to the ICU which was then divided into 4 quartiles. The greater HOUSES, the higher SES, outcomes were adjusted for age, 24-hour Acute Physiology and Chronic Health Evaluation III score, sex, race/ethnicity, and insurance. Results: Among the eligible 4134 participants, the addresses of 3393 (82%) were successfully geocoded and formulated into HOUSES. The adjusted odds ratios comparing HOUSES 1 versus 2, 3, and 4 demonstrated lower likelihood of advance directives −0.77(95% CI: 0.63-0.93) and lower likelihood of discharge to home −0.60(95% CI: 1.0.5-0.72). Conclusion: Lower SES, derived from a composite index of housing attributes, was associated with lower rates of advance directives and lower likelihood of discharge to home.

“…15 Sociodemographic factors that influence ACP have also been explored, with wide variation by race/ethnicity, 16 gender, 17 and education level. 18 However, the socioeconomic factors that may affect ACP are relatively unexplored in the literature, despite the association of socioeconomic status with respect to nearly every health-related outcome, ranging from quality of care to mortality. 19 Furthermore, there is a gap in the literature on the contextual forces that influence ACP.…”

Section: Introductionmentioning

confidence: 99%

Factors Influencing Advance Care Planning Among Older Adults in Two Socioeconomically Diverse Living Communities

Tripken

Elrod

Bills

2016

Background/Objectives: Advance care planning (ACP) is an iterative, complex, and dynamic process of discussion, decisionmaking, and documentation about end-of-life care. The extent to which this process takes place in older adults in diverse socioeconomic settings is not well documented. The aim of this study was to assess the knowledge, attitudes, and beliefs about ACP among older adults in two socioeconomically diverse settings to identify the individual and contextual factors that influence behaviors regarding end-of-life care. Design: A cross-sectional survey design was used. Setting: An affordable independent continuing care retirement community and a high-income eligible (HIE) independent continuing care retirement community. Participants: Individuals aged 55 years and older who resided in independent living. Measurements: A 61-item survey was administered. Simple descriptive statistics were used to examine the responses, and inferential statistics were used to evaluate which items were associated with key outcomes between the 2 settings. Results: Seventy-seven older adults completed the survey. Significant differences in familiarity of terminology and knowledge of ACP, as well as significant differences in completion of advance directives and communication, were found between the 2 communities. No differences were found in attitudes and beliefs about end-of-life issues. Conclusion: Higher levels of knowledge and engagement in ACP were reported at the HIE community as compared to the affordable housing community. These findings provide insight into the influence of the contextual forces that encourage and support ACP.