OBJECTIVE
To examine inpatient intensive care unit (ICU) and intensive procedure use by race among Medicare decedents, using utilization among survivors for comparison.
DESIGN
Retrospective observational analysis of inpatient claims using multivariable hierarchical logistic regression.
SETTING
United States, 1989–1999.
PARTICIPANTS
Hospitalized Medicare fee-for-service decedents (n = 976,220) and survivors (n = 845,306) aged 65 years or older.
MEASUREMENTS AND MAIN RESULTS
Admission to the ICU and use of one or more intensive procedures over 12 months, and, for inpatient decedents, during the terminal admission. Black decedents with one or more hospitalization in the last 12 months of life were slightly more likely than nonblacks to be admitted to the ICU during the last 12 months (49.3% vs. 47.4%, p <.0001) and the terminal hospitalization (41.9% vs. 40.6%, p < 0.0001), but these differences disappeared or attenuated in multivariable hierarchical logistic regressions (last 12 months adjusted odds ratio (AOR) 1.0 [0.99–1.03], p = .36; terminal hospitalization AOR 1.03 [1.0–1.06], p = .01). Black decedents were more likely to undergo an intensive procedure during the last 12 months (49.6% vs. 42.8%, p < .0001) and the terminal hospitalization (37.7% vs, 31.1%, p < .0001), a difference that persisted with adjustment (last 12 months AOR 1.1 [1.08–1.14], p < .0001; terminal hospitalization AOR 1.23 [1.20–1.26], p < .0001). Patterns of differences in inpatient treatment intensity by race were reversed among survivors: blacks had lower rates of ICU admission (31.2% vs. 32.4%, p < .0001; AOR 0.93 [0.91–0.95], p < .0001) and intensive procedure use (36.6% vs. 44.2%; AOR 0.72 [0.70–0.73], p <.0001). These differences were driven by greater use by blacks of life-sustaining treatments that predominate among decedents but lesser use of cardiovascular and orthopedic procedures that predominate among survivors. A hospital’s black census was a strong predictor of inpatient end-of-life treatment intensity.
CONCLUSIONS
Black decedents were treated more intensively during hospitalization than nonblack decedents, whereas black survivors were treated less intensively. These differences are strongly associated with a hospital’s black census. The causes and consequences of these hospital-level differences in intensity deserve further study.
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Acknowledgements
We thank several anonymous reviewers for their suggestions to improve the report of our findings. An earlier version of this study, “Predictors of Intensive Inpatient Service Use Among the Elderly,” was presented in poster form at the AcademyHealth Annual Research Meeting in Nashville, TN, June, 2003.
Author contributions and data access and responsibility:
Dr. Barnato was responsible for study concept and design, analysis and interpretation of data, and preparation of the manuscript. Dr. Garber obtained the data, and was responsible for study concept and design, analysis and interpretation of data, and providing feedback on drafted manuscripts. Ms. Saynina was responsible for data analytic concept and design and for programming and providing feedback on drafted manuscripts. Dr. Chang was responsible for statistical concept and design, in addition to interpretation of the data and providing feedback on drafted manuscripts. Dr. Barnato had full access to the data while at Stanford (until July 2001); thereafter, and for the version of the analysis reported here, Olga Saynina had full access to the data. Dr. Barnato takes full responsibility for the integrity of the data and the accuracy of the data analysis.
Potential Financial Conflicts of Interest:
None of the authors has any affiliations with or financial involvement, within the past 5 years and foreseeable future (e.g., employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received, or pending royalties) with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. Disclosures: Dr. Barnato: NIH funding, no other disclosures. Dr. Chang: NIH funding, no other disclosures. Ms. Saynina: No disclosures. Dr. Garber: NIH-funding and paid and unpaid consultancies including: the Centers for Medicare and Medicaid Services’ Medicare Coverage Advisory Committee, the national Blue Cross and Blue Shield Association Medical Advisory Panel, the Institute of Medicine, the Congressional Office of Technology Assessment, and the Clinical Efficacy Assessment Project of the American College of Physicians.
Role of the sponsor:
Funding was provided by National Institute on Aging (NIA) grants AG17253 and AG050842 to Stanford University and the National Bureau of Economic Research. Dr. Barnato was supported by NIA career-development grant AG021921. The NIA had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.
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Appendix
Appendix
Intensive procedures included in the study (in alphabetical order)
Amputation of lower extremity
Ankle/foot joint replacement
Aortic resection with replacement
Appendectomy
Arteriogram and venogram (not heart or head)
Automated implantable cardioverter defibrillator (AICD)
Biopsy of spinal cord
Bone marrow transplant
Cardiac assist device/ECMO/bypass
Cardiac catheterization, coronary arteriography
Carotid endarterectomy
Central vessel endarterectomy/thrombectomy
Cerebral arteriogram
Cholecystectomy and common duct exploration
Closed control of UGIB
Colon resection
Coronary artery bypass graft (CABG)
Creation of arteriovenous fistula
Cycstectomy
Electrophysiology study (EPS) +/- ablation
Enterostomy
Esophageal dilation
Esophageal reanastamosis/repair
Esophagectomy
Excision, lysis peritoneal tissue
Exploratory laparotomy
Feeding tube placement
Fundoplication
Genitourinary incontinence procedures
Hemodialysis
Hip replacement, total and partial
Hysterectomy
Ileostomy and colostomy
Injection or ligation of esophageal varices
Insert/repl/revise/remove permananent pacemaker
Insertion, temporary cardiac pacemaker
Intracoronary artery thrombolytic infusion
Intubation and Tracheostomy
Jaw fracture repair
Kidney transplant
Knee replacement
Laminectomy, diskectomy, arthrodesis
Laparoscopic cholecystectomy
Laryngectomy
Lobectomy
Local excision lung/bronchus
Mastectomy
Mastoidectomy
Mediastinoscopy
Nephrectomy
Oophorectomy, unilateral and bilateral
Open biopsy lung/bronchus
Open cholecystectomy
Open CNS biopsy
Open CNS diagnostic procedures
Open CNS therapeutic procedures
Open control of UGIB
Open heart repair of septal defects, etc.
Open or closed cardiac massage
Open Prostatectomy
Orchiectomy
Pancreatectomy/pancreaticoduodenectomy
Partial/total gastrectomy and gastric bypass
Pelvic exenteration
Percutaneous CNS biopsy (stereotactic/burr hole)
Percutaneous transluminal coronary angioplasty (PTCA)
Pericardial procedure
Peripheral vascular bypass
Peripheral vessel endarterectomy/thrombectomy
Pneumonectomy
Pyloroplasty
Radical Prostatectomy
Regional/radical lymph-node dissection
Revision/repair of vessel/vascular Procedure
Skin graft
Small bowel resection
Splenectomy
Surgical removal of urinary calculus
Thoracotomy
Thyroidectomy
Transurethral Prostatectomy (TURP)
Treatment, fracture of hip and femur
Treatment, fracture of lower extremity
Treatment, fracture of radius and ulna
Vagotomy
Valve procedures (including replacement)
Vena cava interruption
Ventricular shunt
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Barnato, A.E., Chang, CC.H., Saynina, O. et al. Influence of Race on Inpatient Treatment Intensity at the End of Life. J GEN INTERN MED 22, 338–345 (2007). https://doi.org/10.1007/s11606-006-0088-x
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DOI: https://doi.org/10.1007/s11606-006-0088-x