The Influence of Race and Ethnicity on End-of-Life Care in the Intensive Care Unit

Transcription

1 The Influence of Race and Ethnicity on End-of-Life Care in the Intensive Care Unit Sarah Muni, MD Department of Medicine Chair s Rounds November 10, 2009

2 Health Disparities Research Clinical appropriateness Q U A L I T Y Patient preferences Operation of Healthcare Systems and the Legal and Regulatory Climate Discrimination: Biases, Prejudice, Stereotyping and Uncertainty IOM 2002

3 Background A large and growing body of evidence demonstrates the existence of racial and ethnic differences and disparities in health care. Relatively few studies have examined the influence of race and ethnicity on ICU care. The ICU is often the site of end-of-life care. There is no conclusive data on the influence of race on end-of-life care in the ICU.

4 Research Question Is end-of-life care in the ICU influenced by race and ethnicity?

5 Methods: Population and Setting Cluster-randomized trial 15 hospitals in Seattle-Tacoma Area Inclusion criteria: - Patients who died > 6hours after admission to ICU or <30 hours after transfer from ICU. No exclusion criteria

6 Methods: Data Predictor variables: Race and ethnicity Covariates: Patient age and sex Hospital site Income Education Health insurance Outcome variables: Evidence of advance care planning Use of life sustaining therapies Symptom management Communication about end-of-life care Use of support services

7 Methods: Statistical Analysis Descriptive analysis T-test Mann-Whitney Chi square Multivariate logistic regression Model 1: Patient age and sex Hospital site Model 2: Patient age and sex Hospital site Income Insurance type Education level

8 Results: Sample Characteristics Characteristic White (n=2479) Non-white (n=659) Patient Age (mean± SD) 70.3 ± ±16.5 <0.001 Female Patients (%) 41.3 (1025) 42.3 (279) 0.65 ICU LOS a Median (IQR) b 2.7 days (1.0, 6.7 days) 2.8 days (1.0, 6.6 days ) 0.80 P Household Income (median ± SD) 50,800±13,700 45,600±12,200 <0.001 Cause of death % (n) 0.64 Trauma 10.0 (249) 9.4 (62) Cancer 14.0 (347) 15.3 (101) Other cause 76 (1883) 75.3 (496) Education Level % (n) <0.001 No High School Diploma 14.1 (341) 28.4 (180) High School Diploma 66.1 (1604) 55.1 (349) College Degree 19.8 (480) 16.4 (104) Insurance % (n) <0.001 Insured 88.2 (2187) 70.4 (464) Underinsured 11.8 (292) 29.6 (195) a LOS = length of stay; b IQR = interquartile range.

9 Advance Care Planning N (3138) White %(n) Non-white % (n) Adjusted* Odds Ratio (95% CI) Presence of Living Will (1026) 32.9 (124) 0.41 ( ) Documentation of DPOAHC (1048) 52.2 (168) 0.53 ( ) *Adjusted for age, sex, hospital site, income, education and insurance type

10 Life Sustaining Therapies N (3138) White %(n) Non-white % (n) Adjusted* Odds Ratio (95% CI) Patient died with life sustaining therapies (614) 35.6 (233) 1.59 ( ) DNR order in place (2039) 76.9 (503) 0.76 ( ) Comfort care orders in place at time of death Ventilator withdrawn prior to death (1114 ) 38.7 (255) 0.77 ( ) (1437) 55.9 (326) 0.59 ( ) *Adjusted for age, sex, hospital site, income, education and insurance type

11 Symptom Management N (3138) White %(n) Non-white % (n) Adjusted* Odds Ratio (95% CI) SYMPOTMS DOCUMENTED AS ASSESSED Pain (2025) 78.9 (520) 0.98 ( ) Dyspnea (1175) 42.5 (280) 0.84 ( ) Restlessness or agitation (1075) 36.3 (239) 0.80 ( ) Anxiousness (383) 12.1 (80) 0.84 ( ) Confusion or delirium (481) 13.1 (86) 0.63 ( ) SYMPTOMS DOCUMENTED AS PRESENT Pain present (845) 35.7 (185) 0.79 ( ) Dyspnea present (710) 58.6 (164) 1.05 ( ) Restlessness or agitation (599) 54.0 (129) 0.95 ( ) Anxiousness (271) 63.8 (51) 0.47 ( ) Confusion or delirium (340) 61.6 (53) 0.67 ( ) *Adjusted for age, sex, hospital site, income, education and insurance type

12 Conference and Communication Adjusted* Documented element N (3138) White %(n) Non-white % (n) Odds Ratio (95% CI) Family conference occurred within the first 72 hours of admission to the ICU (1801) 72.9 (479) 1.14 ( ) Prognosis was discussed during conference (889) 44.3 (291) 1.47 ( ) Patient s opinion and wishes were expressed Patient expressed wishes to withdrawal life support Family expressed wishes to withdrawal life support Physician recommended withdrawal of life support (631) 17.2 (113) 0.63 ( ) (275) 5.3 (35) 0.45 ( ) (1116) 39.6 (260) 0.89 ( ) (137) 9.3 (61) 1.57 ( ) Discord occurred (122) 7.9 (52) 1.49 ( ) Spirituality was addressed (795) 35.0 (230) 1.10 ( ) *Adjusted for age, sex, hospital site, income, education and insurance type

13 Social and Spiritual Services N (3138) White %(n) Non-white % (n) Adjusted* Odds Ratio (95% CI) Social work involvement (1035) 45.3 (298) 1.28 ( ) Spiritual care involvement (1119) 49.1 (323) 1.09 ( ) *Adjusted for age, sex, hospital site, income, education and insurance type

14 Results Summary Non-white patients were less likely to have ACP and more likely to die with life sustaining measures. Documentation of conferences differed in white versus non-white patients. There is no clear influence of race/ethnicity on symptom management. Non-white patients more likely to have social work involvement in care.

15 Important Limitations Descriptive study Results are dependent on the accuracy of documentation Relatively small non-white study sample NW regionality

16 Conclusions There are racial and ethnic differences in end-of-life care in the ICU independent of socioeconomic factors. These differences appear to be driven by cultural preferences about end-of-life care but may also represent racial and ethnic disparities Improving end-of-life care in the ICU for all and eliminating disparities in care requires full understanding of these issues.

17 References 1. Smedley BD, Stith AY, Nelson AR. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington D.C.: The National Academy Press, Barnato AE, Alexander SL, Linde-Zwirble WT, et al. Racial variation in the incidence, care, and outcomes of severe sepsis: analysis of population, patient, and hospital characteristics. Am J Respir Crit Care Med 2008; 177: Borum ML, Lynn J, Zhong Z. The effects of patient race on outcomes in seriously ill patients in SUPPORT: An overview of economic impact, medical intervention, and endof-life decisions. J Am Geriatr Soc 2000; 48:S194-S Williams J, Zimmerman J, DP W, et al. African-American and white patients admitted to the intensive care unit: Is there a difference in therapy and outcome? Critical Care Medicine 1995; 23: Barnato AE, Berhane Z, Weissfeld LA, et al. Racial variation in end-of-life intensive care use: a race or hospital effect? Health Serv Res 2006; 41: Degenholtz HB, Thomas SB, Miller MJ. Race and the intensive care unit: disparities and preferences for end-of-life care. Crit Care Med 2003; 31:S Angus DC, Barnato AE, Linde-Zwirble WT, et al. Use of intensive care at the end of life in the United States: An epidemiologic study. Crit Care Med 2004; 32: Curtis JR, Treece PD, Nielsen EL, Downey L, Shannon SE, Braungardt T, Owens D, Steinberg KP, Engelberg RA. Integrating palliative and critical care: Evaluation of a Quality Improvement Intervention. Am J Respir Crit Care Med Aug 1;178(3):

18 Thank you! J. Randall Curtis, MD, MPH Ruth Engelberg, PhD Lois Downey, MA Patsy Treece, MSW Danae Dotolo, MSW End-of-Life Care Research Program staff Internal Medicine Residency Program Nimish Muni, MD