Race/Ethnicity, Socioeconomic Status, and Healthcare Intensity at the End of Life

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Abstract

Background: Although racial/ethnic minorities receive more intense, nonbeneficial healthcare at the end of life, the role of race/ethnicity independent of other social determinants of health is not well understood. Objectives: Examine the association between race/ethnicity, other key social determinants of health, and healthcare intensity in the last 30 days of life for those with chronic, life-limiting illness. Subjects: We identified 22,068 decedents with chronic illness cared for at a single healthcare system in Washington State who died between 2010 and 2015 and linked electronic health records to death certificate data. Design: Binomial regression models were used to test associations of healthcare intensity with race/ethnicity, insurance status, education, and median income by zip code. Path analyses tested direct and indirect effects of race/ethnicity with insurance, education, and median income by zip code used as mediators. Measurements: We examined three measures of healthcare intensity: (1) intensive care unit admission, (2) use of mechanical ventilation, and (3) receipt of cardiopulmonary resuscitation. Results: Minority race/ethnicity, lower income and educational attainment, and Medicaid and military insurance were associated with higher intensity care. Socioeconomic disadvantage accounted for some of the higher intensity in racial/ethnic minorities, but most of the effects were direct effects of race/ethnicity. Conclusions: The effects of minority race/ethnicity on healthcare intensity at the end of life are only partly mediated by other social determinants of health. Future interventions should address the factors driving both direct and indirect effects of race/ethnicity on healthcare intensity.

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Patient-centered communication, ratings of care, and concordance of patient and physician race.

Lisa Cooper, Debra Roter, Rachel Johnson … (2003)

African-American patients who visit physicians of the same race rate their medical visits as more satisfying and participatory than do those who see physicians of other races. Little research has investigated the communication process in race-concordant and race-discordant medical visits. To compare patient-physician communication in race-concordant and race-discordant visits and examine whether communication behaviors explain differences in patient ratings of satisfaction and participatory decision making. Cohort study with follow-up using previsit and postvisit surveys and audiotape analysis. 16 urban primary care practices. 252 adults (142 African-American patients and 110 white patients) receiving care from 31 physicians (of whom 18 were African-American and 13 were white). Audiotape measures of patient-centeredness, patient ratings of physicians' participatory decision-making styles, and overall satisfaction. Race-concordant visits were longer (2.15 minutes [95% CI, 0.60 to 3.71]) and had higher ratings of patient positive affect (0.55 point, [95% CI, 0.04 to 1.05]) compared with race-discordant visits. Patients in race-concordant visits were more satisfied and rated their physicians as more participatory (8.42 points [95% CI, 3.23 to 13.60]). Audiotape measures of patient-centered communication behaviors did not explain differences in participatory decision making or satisfaction between race-concordant and race-discordant visits. Race-concordant visits are longer and characterized by more patient positive affect. Previous studies link similar communication findings to continuity of care. The association between race concordance and higher patient ratings of care is independent of patient-centered communication, suggesting that other factors, such as patient and physician attitudes, may mediate the relationship. Until more evidence is available regarding the mechanisms of this relationship and the effectiveness of intercultural communication skills programs, increasing ethnic diversity among physicians may be the most direct strategy to improve health care experiences for members of ethnic minority groups.

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Health care costs in the last week of life: associations with end-of-life conversations.

Baohui Zhang, Alexi A Wright, Haiden Huskamp … (2009)

Life-sustaining medical care of patients with advanced cancer at the end of life (EOL) is costly. Patient-physician discussions about EOL wishes are associated with lower rates of intensive interventions. Funded by the National Institute of Mental Health and the National Cancer Institute, Coping With Cancer is a longitudinal multi-institutional study of 627 patients with advanced cancer. Patients were interviewed at baseline and were followed up through death. Costs for intensive care unit and hospital stays, hospice care, and life-sustaining procedures (eg, mechanical ventilator use and resuscitation) received in the last week of life were aggregated. Generalized linear models were applied to test for cost differences in EOL care. Propensity score matching was used to reduce selection biases. Of 603 participants, 188 (31.2%) reported EOL discussions at baseline. After propensity score matching, the remaining 415 patients did not differ in sociodemographic characteristics, recruitment sites, illness acknowledgment, or treatment preferences. Further analyses, adjusted by quintiles of propensity scores and significant confounders, revealed that the mean (SE) aggregate costs of care (in 2008 US dollars) were $1876 ($177) for patients who reported EOL discussions compared with $2917 ($285) for patients who did not, a cost difference of $1041 (35.7% lower among patients who reported EOL discussions) (P =.002). Patients with higher costs had worse quality of death in their final week (Pearson production moment correlation partial r = -0.17, P =.006). Patients with advanced cancer who reported having EOL conversations with physicians had significantly lower health care costs in their final week of life. Higher costs were associated with worse quality of death.

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The associations of clinicians' implicit attitudes about race with medical visit communication and patient ratings of interpersonal care.

K Carson, Caroline Sabin, Mary Beach … (2012)

We examined the associations of clinicians' implicit attitudes about race with visit communication and patient ratings of care. In a cross-sectional study of 40 primary care clinicians and 269 patients in urban community-based practices, we measured clinicians' implicit general race bias and race and compliance stereotyping with 2 implicit association tests and related them to audiotape measures of visit communication and patient ratings. Among Black patients, general race bias was associated with more clinician verbal dominance, lower patient positive affect, and poorer ratings of interpersonal care; race and compliance stereotyping was associated with longer visits, slower speech, less patient centeredness, and poorer ratings of interpersonal care. Among White patients, bias was associated with more verbal dominance and better ratings of interpersonal care; race and compliance stereotyping was associated with less verbal dominance, shorter visits, faster speech, more patient centeredness, higher clinician positive affect, and lower ratings of some aspects of interpersonal care. Clinician implicit race bias and race and compliance stereotyping are associated with markers of poor visit communication and poor ratings of care, particularly among Black patients.

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Author and article information

Journal

Title: Journal of Palliative Medicine

Abbreviated Title: Journal of Palliative Medicine

Publisher: Mary Ann Liebert Inc

ISSN (Print): 1096-6218

ISSN (Electronic): 1557-7740

Publication date Created: September 2018

Publication date (Print): September 2018

Volume: 21

Issue: 9

Pages: 1308-1316

Affiliations

[1 ]Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington.

[2 ]Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington.

[3 ]Division of General Internal Medicine, University of Washington, Seattle, Washington.

[4 ]Department of Family Medicine, University of Washington, Seattle, Washington.

[5 ]Department of Bioinformatics and Medical Education, University of Washington, Seattle, Washington.

[6 ]Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington.

[7 ]Seattle Cancer Care Alliance, Seattle, Washington.

[8 ]Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.

Article

DOI: 10.1089/jpm.2018.0011

PMC ID: 6154447

PubMed ID: 29893618

SO-VID: 4c43346e-8fbb-4776-93ee-fd9805d5e677

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Race/Ethnicity, Socioeconomic Status, and Healthcare Intensity at the End of Life

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Most cited references 23

Patient-centered communication, ratings of care, and concordance of patient and physician race.

Health care costs in the last week of life: associations with end-of-life conversations.

The associations of clinicians' implicit attitudes about race with medical visit communication and patient ratings of interpersonal care.

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