Black Patients More Likely to Receive High-Cost Care at End of Life

Multiple studies have demonstrated that black Americans tend to receive more intensive, higher-cost care at the end of life, and have higher rates of hospitalization and lower rates of hospice enrollment. A new study, presented at the American Geriatrics Society 2017 Annual Meeting and published in the Journal of the American Geriatrics Society, sought to determine whether racial variation exists among hospice enrollees in rates of hospitalization and hospice disenrollment, and whether that variation could be explained by systematic differences in hospice provider patterns.

Researchers Jessica Rizzuto, MPP, and Melissa D. Aldridge, PhD, MBA, both of the Icahn School of Medicine at Mount Sinai, used data from a longitudinal cohort study of Medicare beneficiaries (n = 145,038) enrolled in Medicare-certified hospices, and followed the patients until death during the years 2009 to 2010. Of the enrollees, 92.4% were white patients, and 7.6% were black patients.

Rizzuto and Aldridge found that, overall:

• 8.7% of white patients versus 14.9% of black patients were admitted to the hospital
• 13.5% of white patients versus 19.8% of black patients visited the emergency department (ED)
• 13.0% of white patients versus 18.1% were disenrolled from hospice

In fully adjusted models that including hospice random effects as well as demographic and clinical characteristics, black patients had higher odds of hospital admission (odds ratio [OR] 1.75; 95% CI, 1.64-1.86), ED visits (OR 1.61; 95%CI, 1.52-1.70), and disenrollment from hospice (OR 1.54; 95% CI, 1.45-1.63).

Rizzuto and Aldridge concluded that rates of hospital utilization and hospice disenrollment by black patients compared with white patients are attributable to racial differences within the same hospice, rather than to systematic differences between hospices in hospital utilization and hospice disenrollment rates.

“While differences exist between hospice organizations in how frequently their patients are hospitalized, including time in the emergency room, and disenrollment from hospice, these patterns do not explain racial disparities between blacks and whites in hospital use and hospice disenrollment,” said Aldridge in a statement.

The researchers posit that black patients may be more likely to have a preference for life-sustaining therapies, which may be attributable to spiritual beliefs that stand in conflict to the goals of hospice care.

Another possible explanation is that patterns of provider communication with patients may result in a lack of understanding of hospice care and potentially inappropriate hospice enrollment; the authors point to a study of patients with chronic kidney disease in which researchers found that black patients were less likely than white patients to have had end-of-life discussions with their healthcare providers.

Finally, black patients may face higher barriers to access to certain key resources, such as pharmacies that stock adequate quantities of the medications that they need, even when compared to white patients at the same hospice, causing black patients to resort to using the hospital or disenrolling from hospice care.

“Our findings underscore the need to better understand racial disparities in outcomes after hospice enrollment,” added Aldridge. “Culturally sensitive interventions that increase understanding of hospice, address shortcomings in provider communication, and improve caregiver resources could help decrease these persistent differences in outcomes.”