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Influence of Race on Inpatient Treatment Intensity at the End of Life

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Journal of General Internal Medicine Aims and scope Submit manuscript

OBJECTIVE

To examine inpatient intensive care unit (ICU) and intensive procedure use by race among Medicare decedents, using utilization among survivors for comparison.

DESIGN

Retrospective observational analysis of inpatient claims using multivariable hierarchical logistic regression.

SETTING

United States, 1989–1999.

PARTICIPANTS

Hospitalized Medicare fee-for-service decedents (n = 976,220) and survivors (n = 845,306) aged 65 years or older.

MEASUREMENTS AND MAIN RESULTS

Admission to the ICU and use of one or more intensive procedures over 12 months, and, for inpatient decedents, during the terminal admission. Black decedents with one or more hospitalization in the last 12 months of life were slightly more likely than nonblacks to be admitted to the ICU during the last 12 months (49.3% vs. 47.4%, p <.0001) and the terminal hospitalization (41.9% vs. 40.6%, p < 0.0001), but these differences disappeared or attenuated in multivariable hierarchical logistic regressions (last 12 months adjusted odds ratio (AOR) 1.0 [0.99–1.03], p = .36; terminal hospitalization AOR 1.03 [1.0–1.06], p = .01). Black decedents were more likely to undergo an intensive procedure during the last 12 months (49.6% vs. 42.8%, p < .0001) and the terminal hospitalization (37.7% vs, 31.1%, p < .0001), a difference that persisted with adjustment (last 12 months AOR 1.1 [1.08–1.14], p < .0001; terminal hospitalization AOR 1.23 [1.20–1.26], p < .0001). Patterns of differences in inpatient treatment intensity by race were reversed among survivors: blacks had lower rates of ICU admission (31.2% vs. 32.4%, p < .0001; AOR 0.93 [0.91–0.95], p < .0001) and intensive procedure use (36.6% vs. 44.2%; AOR 0.72 [0.70–0.73], p <.0001). These differences were driven by greater use by blacks of life-sustaining treatments that predominate among decedents but lesser use of cardiovascular and orthopedic procedures that predominate among survivors. A hospital’s black census was a strong predictor of inpatient end-of-life treatment intensity.

CONCLUSIONS

Black decedents were treated more intensively during hospitalization than nonblack decedents, whereas black survivors were treated less intensively. These differences are strongly associated with a hospital’s black census. The causes and consequences of these hospital-level differences in intensity deserve further study.

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Acknowledgements

We thank several anonymous reviewers for their suggestions to improve the report of our findings. An earlier version of this study, “Predictors of Intensive Inpatient Service Use Among the Elderly,” was presented in poster form at the AcademyHealth Annual Research Meeting in Nashville, TN, June, 2003.

Author contributions and data access and responsibility:

Dr. Barnato was responsible for study concept and design, analysis and interpretation of data, and preparation of the manuscript. Dr. Garber obtained the data, and was responsible for study concept and design, analysis and interpretation of data, and providing feedback on drafted manuscripts. Ms. Saynina was responsible for data analytic concept and design and for programming and providing feedback on drafted manuscripts. Dr. Chang was responsible for statistical concept and design, in addition to interpretation of the data and providing feedback on drafted manuscripts. Dr. Barnato had full access to the data while at Stanford (until July 2001); thereafter, and for the version of the analysis reported here, Olga Saynina had full access to the data. Dr. Barnato takes full responsibility for the integrity of the data and the accuracy of the data analysis.

Potential Financial Conflicts of Interest:

None of the authors has any affiliations with or financial involvement, within the past 5 years and foreseeable future (e.g., employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received, or pending royalties) with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. Disclosures: Dr. Barnato: NIH funding, no other disclosures. Dr. Chang: NIH funding, no other disclosures. Ms. Saynina: No disclosures. Dr. Garber: NIH-funding and paid and unpaid consultancies including: the Centers for Medicare and Medicaid Services’ Medicare Coverage Advisory Committee, the national Blue Cross and Blue Shield Association Medical Advisory Panel, the Institute of Medicine, the Congressional Office of Technology Assessment, and the Clinical Efficacy Assessment Project of the American College of Physicians.

Role of the sponsor:

Funding was provided by National Institute on Aging (NIA) grants AG17253 and AG050842 to Stanford University and the National Bureau of Economic Research. Dr. Barnato was supported by NIA career-development grant AG021921. The NIA had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Author information

Authors and Affiliations

  1. Center for Research on Health Care, University of Pittsburgh, 200 Meyran Ave., Suite 200, Pittsburgh, PA, 15213, USA

    Amber E. Barnato MD, MPH, MS & Chung-Chou H. Chang PhD

  2. National Bureau of Economic Research, Inc., Palo Alto, CA, USA

    Olga Saynina MA, MBA & Alan M. Garber MD, PhD

  3. Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA

    Alan M. Garber MD, PhD

  4. Stanford University School of Medicine, Stanford, CA, USA

    Alan M. Garber MD, PhD

Authors
  1. Amber E. Barnato MD, MPH, MS
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  2. Chung-Chou H. Chang PhD
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  3. Olga Saynina MA, MBA
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  4. Alan M. Garber MD, PhD
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Corresponding author

Correspondence to Amber E. Barnato MD, MPH, MS.

Appendix

Appendix

Intensive procedures included in the study (in alphabetical order)

Amputation of lower extremity

Ankle/foot joint replacement

Aortic resection with replacement

Appendectomy

Arteriogram and venogram (not heart or head)

Automated implantable cardioverter defibrillator (AICD)

Biopsy of spinal cord

Bone marrow transplant

Cardiac assist device/ECMO/bypass

Cardiac catheterization, coronary arteriography

Carotid endarterectomy

Central vessel endarterectomy/thrombectomy

Cerebral arteriogram

Cholecystectomy and common duct exploration

Closed control of UGIB

Colon resection

Coronary artery bypass graft (CABG)

Creation of arteriovenous fistula

Cycstectomy

Electrophysiology study (EPS) +/- ablation

Enterostomy

Esophageal dilation

Esophageal reanastamosis/repair

Esophagectomy

Excision, lysis peritoneal tissue

Exploratory laparotomy

Feeding tube placement

Fundoplication

Genitourinary incontinence procedures

Hemodialysis

Hip replacement, total and partial

Hysterectomy

Ileostomy and colostomy

Injection or ligation of esophageal varices

Insert/repl/revise/remove permananent pacemaker

Insertion, temporary cardiac pacemaker

Intracoronary artery thrombolytic infusion

Intubation and Tracheostomy

Jaw fracture repair

Kidney transplant

Knee replacement

Laminectomy, diskectomy, arthrodesis

Laparoscopic cholecystectomy

Laryngectomy

Lobectomy

Local excision lung/bronchus

Mastectomy

Mastoidectomy

Mediastinoscopy

Nephrectomy

Oophorectomy, unilateral and bilateral

Open biopsy lung/bronchus

Open cholecystectomy

Open CNS biopsy

Open CNS diagnostic procedures

Open CNS therapeutic procedures

Open control of UGIB

Open heart repair of septal defects, etc.

Open or closed cardiac massage

Open Prostatectomy

Orchiectomy

Pancreatectomy/pancreaticoduodenectomy

Partial/total gastrectomy and gastric bypass

Pelvic exenteration

Percutaneous CNS biopsy (stereotactic/burr hole)

Percutaneous transluminal coronary angioplasty (PTCA)

Pericardial procedure

Peripheral vascular bypass

Peripheral vessel endarterectomy/thrombectomy

Pneumonectomy

Pyloroplasty

Radical Prostatectomy

Regional/radical lymph-node dissection

Revision/repair of vessel/vascular Procedure

Skin graft

Small bowel resection

Splenectomy

Surgical removal of urinary calculus

Thoracotomy

Thyroidectomy

Transurethral Prostatectomy (TURP)

Treatment, fracture of hip and femur

Treatment, fracture of lower extremity

Treatment, fracture of radius and ulna

Vagotomy

Valve procedures (including replacement)

Vena cava interruption

Ventricular shunt

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Barnato, A.E., Chang, CC.H., Saynina, O. et al. Influence of Race on Inpatient Treatment Intensity at the End of Life. J GEN INTERN MED 22, 338–345 (2007). https://doi.org/10.1007/s11606-006-0088-x

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