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The American Journal of Managed Care February 2020
Care Coordination for Veterans With COPD: A Positive Deviance Study
Ekaterina Anderson, PhD; Renda Soylemez Wiener, MD, MPH; Kirsten Resnick, MS; A. Rani Elwy, PhD; and Seppo T. Rinne, MD, PhD
Expand Predeductible Coverage Without Increasing Premiums or Deductibles
A. Mark Fendrick, MD
From the Editorial Board: Jeffrey D. Dunn, PharmD, MBA
Jeffrey D. Dunn, PharmD, MBA
Do Americans Have the Political Will to Tackle Healthcare Costs? A Q&A With Gail Wilensky, PhD
Interview by Allison Inserro
Risk Adjustment in Home Health Care CAHPS
Lisa M. Lines, PhD, MPH; Wayne L. Anderson, PhD; Harper Gordek, MPH; and Anne E. Kenyon, MBA
Reply to “Risk Adjustment in Home Health Care CAHPS”
Hsueh-Fen Chen, PhD; J. Mick Tilford, PhD; Robert F. Schuldt, MA; and Fei Wan, PhD
Preventive Drug Lists as Tools for Managing Asthma Medication Costs
Melissa B. Gilkey, PhD; Lauren A. Cripps, MA; Rachel S. Gruver, MPH; Deidre V. Washington, PhD; and Alison A. Galbraith, MD, MPH
Co-payment Policies and Breast and Cervical Cancer Screening in Medicaid
Lindsay M. Sabik, PhD; Anushree M. Vichare, PhD; Bassam Dahman, PhD; and Cathy J. Bradley, PhD
Discontinuation of New Hepatitis C Drugs Among Medicare Patients
Jeah Jung, PhD, MPH; Ping Du, MD, PhD; Roger Feldman, PhD; and Thomas Riley III, MD
A Population-Based Assessment of Proton Beam Therapy Utilization in California
Arti Parikh-Patel, PhD, MPH; Cyllene R. Morris, DVM, PhD; Frances B. Maguire, PhD, MPH; Megan E. Daly, MD; and Kenneth W. Kizer, MD, MPH
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Racial and Ethnic Disparity in Palliative Care and Hospice Use
Tricia Johnson, PhD; Surrey Walton, PhD; Stacie Levine, MD; Erik Fister, MA; Aliza Baron, MA; and Sean O’Mahony, MB, BCh, BAO
Economic Value of Transcatheter Valve Replacement for Inoperable Aortic Stenosis
Jesse Sussell, PhD; Emma van Eijndhoven, MS, MA; Taylor T. Schwartz, MPH; Suzanne J. Baron, MD, MSc; Christin Thompson, PhD; Seth Clancy, MPH; and Anupam B. Jena, MD, PhD
Impact of Complex Care Management on Spending and Utilization for High-Need, High-Cost Medicaid Patients
Brian W. Powers, MD, MBA; Farhad Modarai, DO; Sandeep Palakodeti, MD, MPH; Manisha Sharma, MD; Nupur Mehta, MD; Sachin H. Jain, MD, MBA; and Vivek Garg, MD, MBA
Medical Utilization Surrounding Initial Opioid-Related Diagnoses by Coding Method
Amber Watson, PharmD; David M. Simon, PhD; Meridith Blevins Peratikos, MS; and Elizabeth Ann Stringer, PhD

Racial and Ethnic Disparity in Palliative Care and Hospice Use

Tricia Johnson, PhD; Surrey Walton, PhD; Stacie Levine, MD; Erik Fister, MA; Aliza Baron, MA; and Sean O’Mahony, MB, BCh, BAO
Race/ethnicity was not a predictor of inpatient palliative care consultation or discharge to hospice in 4 hospitals with an inpatient palliative care service.
ABSTRACT

Objectives:
Prior research has demonstrated differences across race and ethnicity, as well as across geographic location, in palliative care and hospice use for patients near the end of life. However, there remains inconsistent evidence regarding whether these disparities are explained by hospital-level practice variation. The goals of this study were to evaluate whether inpatient palliative care consultation use and discharge to hospice differed by race/ethnicity and whether hospital-level variations explained these differences.

Study Design: Retrospective, cross-sectional study.

Methods: This study evaluated 5613 patients who were discharged to hospice or died during their hospital stay between 2012 and 2014 in 4 urban hospitals with an inpatient palliative care service. The main outcomes were receipt of an inpatient palliative care consultation and discharge to hospice.

Results: The sample was 43% white, 44% African American, and 13% Hispanic. After adjusting for patient characteristics and hospital site, race/ethnicity was not significantly associated with receipt of inpatient palliative care consultation. Hispanic race/ethnicity was associated with a higher likelihood of discharge to hospice (odds ratio, 1.22; P = .036), and inpatient palliative care consultation was associated with 4 times higher likelihood of discharge to hospice (P <.001). Hospital site was also associated with both receipt of inpatient palliative care consultation and discharge to hospice.

Conclusions: Our results illustrate significant variation across hospitals in palliative care consultation use and discharge to hospice. No significant racial/ethnic disparities in the use of either palliative care or hospice at the end of life were found within hospitals.

Am J Manag Care. 2020;26(2):e36-e40
Takeaway Points

This study evaluated whether inpatient palliative care consultation use and discharge to hospice differed by race/ethnicity and whether hospital-level variations explained differences in 4 urban hospitals with an inpatient palliative care service.
  • We found significant variation in palliative care consultation use and discharge to hospice across hospitals.
  • After controlling for patient demographic characteristics and hospital, we found no evidence of racial/ethnic disparities in the use of either palliative care or hospice at the end of life.
  • Future work should evaluate whether standardized palliative care education reduces hospital-level variation in the use of both palliative care and hospice.
Multiple studies have shown that hospitals with inpatient palliative medicine consultation teams reduce direct costs,1-6 decrease intensive care unit utilization,3-5,7 and improve quality of care.7-9 In addition, patients who receive an inpatient palliative care consultation are more likely to be referred to and enroll in hospice care.3,10,11 Despite recent evidence that hospice use among racial and ethnic minorities has increased, racial disparities in palliative and end-of-life care persist.12-15

Evidence on the role of race and ethnicity in explaining differences in inpatient palliative care and hospice use has been mixed. Several multisite studies found that African American and Hispanic patients were less likely to use hospice or advanced care planning,16-18 whereas 1 single-site study, by Sharma et al,19 found that African American patients with cancer were more likely than white patients to receive palliative care consultation and more likely than Hispanic cancer patients to be referred to hospice. Burgio et al20 found no racial or ethnic differences in inpatient palliative care use across 6 Veterans Affairs hospitals. Several single-site studies have also found no difference in use of inpatient palliative care consultations8,21 or hospice enrollment22 by race or ethnicity, suggesting that differences may be due to between-hospital variation.

Further, substantial variation exists across hospitals in end-of-life care,23 and several studies have reported that racial discrepancies in end-of-life treatment intensity and cost were partially explained by geographical region and institution.24-26 However, Hardy et al27 found uniform racial disparities in hospice use in urban and rural areas alike. Also, although interdisciplinary consultation teams are commonly used in palliative care in the hospital setting,28 there is substantial variation in the structure and organization of those programs. It remains an open question whether observed differences in palliative care and hospice use among racial and ethnic groups are due to hospital-level variation or disparities within hospitals. The objectives of this study were to (1) compare inpatient palliative care consultation and hospice use by race/ethnicity for hospitalized patients at the end of life and (2) evaluate the extent to which variation in the receipt of inpatient palliative care consultation and hospice use were explained by hospital site versus race/ethnicity and other patient characteristics.

METHODS

This was a retrospective study of discharge-level data for 2012 to 2014 from 4 hospitals with a fellow (physician, nurse, social worker, or chaplain) participating in the Coleman Palliative Medicine Training Program.29,30 The purpose of the training program was to improve access to and quality of palliative care services in Chicago. The study protocol was approved by the Rush University Medical Center institutional review board. Hospitals provided data for end-of-life patients, defined as those who were discharged to hospice or died during the hospital stay, and indicated whether each patient received an inpatient palliative care consultation during the final hospitalization. The hospitals were located within the Chicago metropolitan area and included 2 academic medical centers and 2 community hospitals, with a combined total of more than 80,000 discharges annually. The time frame included discharges between January 2012 and December 2014. When a patient had multiple hospital admissions, only the last admission was included in the analysis. The sample was further limited to patients with a race or ethnicity of non-Hispanic white, non-Hispanic African American, or Hispanic.

Patient and Hospital Characteristics

Other independent variables included race/ethnicity (non-Hispanic African American, non-Hispanic white, Hispanic), gender, age, primary payer, and primary diagnosis. Primary diagnosis was classified into 6 categories using the Healthcare Cost and Utilization Project Clinical Classification Software: circulatory disease, infectious disease, injury or poisoning, neoplasms, respiratory disease, and all other conditions. Additionally, unique identifiers were created for each hospital.

Outcomes

The outcomes of interest were receipt of an inpatient palliative care consultation during the final hospital admission (yes/no) and location of death (hospice, hospital). Patients were classified as dying with hospice if they were discharged to hospice in a medical facility or discharged to hospice in home.


 
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