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The Impact of Race on Intensity of Care Provided to Older Adults in the Medical Intensive Care Unit

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Journal of Racial and Ethnic Health Disparities Aims and scope Submit manuscript

Abstract

Background

African-Americans and Hispanics receive disproportionately less aggressive non-critical treatment for chronic diseases than their Caucasian counterparts. However, when it comes to end-of-life care, minority races are purportedly treated more aggressively in Medical Intensive Care Units (MICU) and are more likely to die there.

Objective

We sought to determine the impact of race on the intensity of care provided to older adults in the Medical Intensive Care Unit (MICU) using the Therapeutic Intervention Scoring System-28 (TISS-28) and other MICU interventions.

Methods

This is a prospective study of a cohort of 309 patients aged 60 years and older in the MICU. Interventions such as mechanical ventilation, vasopressors, new onset dialysis, feeding tubes, and pulmonary artery catheterization were recorded. Primary outcomes were TISS-28 scores and MICU interventions.

Results

Non-white patients were younger and had more dementia and delirium although there was no difference in ICU mortality. The amount of critical care delivered to non-white and white patients were equivalent at p ≤ 0.05 based on their respective TISS-28 scores. Non-white patients received more renal replacement therapy than white patients.

Conclusions

Our study adds to the growing body of literature demonstrating that the relationship between race, patient preference, and the intensity of care provided in MICUs is multifaceted. Although prior studies have reported that non-white populations often opt for more aggressive care, the similar proportions of non-white and white “full code” patients in this study suggests that this idea is overly simplistic.

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Abbreviations

ADL:

Activities of Daily Living Scale

APACHE II:

Acute Physiology and Chronic Health Evaluation

CCI:

Charlson Comorbidity Index

COPD:

Chronic Obstructive Pulmonary Disease

IQCODE:

Informant Questionnaire on Cognitive Decline in the Elderly

IADL:

Instrumental Activities of Daily Living Scale

MICU:

Intensive care unit

SAPS:

Simplified Acute Physiology Score

TISS-28:

Therapeutic Intervention Scoring System-28

YNHH:

Yale-New Haven Hospital

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Acknowledgments

Guarantor Statement

C.Chima-Melton takes responsibility for the content of the manuscript, including the data and analysis.

Author Contributions

C.Chima-Melton formulated the research question, conducted the background research and prepared the paper. K. L. B. Araujo managed the data and prepared figures and tables for the paper. T. E. Murphy performed the necessary statistical research and statistical analysis for this paper. M. Pisani enrolled patients and collected the data for this study. In addition, M. Pisani mentored C.Chima-Melton for study design and paper preparation.

Financial/Nonfinancial Disclosures

M. Pisani is a recipient of a NIH K23 Mentored Career Development Award (K23 AG 23023-01A1) and the Chest Foundation and Boehringer Ingelheim Pharmaceuticals, Inc. Clinical Research Award in Women’s Pulmonary Health. T. E. Murphy was supported in part by Grants from the Biostatistics Core of the Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine (no. 2P30AG021342-06).

Funding Information

M. Pisani is a recipient of a NIH K23 Mentored Career Development Award (K23 AG 23023-01A1) and the Chest Foundation and Boehringer Ingelheim Pharmaceuticals, Inc. Clinical Research Award in Women’s Pulmonary Health. T. E. Murphy was supported in part by Grants from the Biostatistics Core of the Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine (no. 2P30AG021342-06).

Conflict of Interests

The authors declare that they have no competing interests.

Informed Consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). Informed consent was obtained from all patients for being included in the study.

Author information

Authors and Affiliations

  1. Pulmonary & Critical Care Section, Cedars Sinai Medical Center, Los Angeles, CA, USA

    Chidinma Chima-Melton

  2. Department of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine and Yale New Haven Hospital, New Haven, CA, USA

    Terrence E. Murphy & Katy L. B. Araujo

  3. Pulmonary & Critical Care Section, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, P.O. Box 208057, New Haven, CT, 06520-8057, USA

    Margaret A. Pisani

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  1. Chidinma Chima-Melton
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  4. Margaret A. Pisani
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Corresponding author

Correspondence to Chidinma Chima-Melton.

Additional information

Key Messages

• Non-white patients received more renal replacement therapies than their white counterparts. We did not detect any other race-based differences in rates of MICU interventions or intensity of care as measured by the TISS-28 score with respect to most aspects of critical care.

• Multivariable analysis delineated the lack of association seen between race and TISS-28 whereas other variables, such as higher BMI, delirium, and intubation, showed a positive correlation with TISS-28 scores.

• In our population of critically ill older adults, despite being significantly younger, non-white patients had similar mortality rates to white patients.

• Our study demonstrates that non-white patients had higher baseline rates of dementia and greater rates of ICU delirium.

• This work adds to the growing body of literature demonstrating that the relationship between race and intensity of care provided is multifaceted, complicated, and cannot be easily generalized.

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Chima-Melton, C., Murphy, T.E., Araujo, K.L.B. et al. The Impact of Race on Intensity of Care Provided to Older Adults in the Medical Intensive Care Unit. J. Racial and Ethnic Health Disparities 3, 365–372 (2016). https://doi.org/10.1007/s40615-015-0162-3

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  • DOI: https://doi.org/10.1007/s40615-015-0162-3

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