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Advance Care Planning and Treatment Intensity Before Death Among Black, Hispanic, and White Patients Hospitalized
Amber E Barnato1,2, Gregory R Johnson3, John D Birkmeyer1,3
1The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
Insights
Black and Hispanic COVID-19 patients received more intensive treatments, including ICU care and mechanical ventilation. This may have reduced mortality disparities but potentially increased burdensome care at the end of life.
Area of Science:
- Health Services Research
- Health Disparities
- Critical Care Medicine
Background:
- Racial and ethnic minorities, particularly Black and Hispanic populations, face disproportionately higher risks of COVID-19 infection, hospitalization, and mortality.
- These disparities are linked to factors including differential exposure risks, higher prevalence of comorbidities, and unequal access to healthcare.
Purpose of the Study:
- To investigate the relationship between race/ethnicity and the intensity of medical treatment decisions for hospitalized COVID-19 patients.
- To analyze how race and ethnicity influence advance care planning, end-of-life care orders, and life-sustaining treatments.
Main Methods:
- A retrospective cohort analysis was conducted using manually abstracted electronic medical records.
- The study included 7,997 patients hospitalized with COVID-19 across 135 community hospitals from March to June 2020.
- Key outcome measures included advance care planning, do-not-resuscitate (DNR) orders, intensive care unit (ICU) admission, mechanical ventilation (MV), and in-hospital mortality.
Main Results:
- While adjusted in-hospital mortality was similar between White and Black patients, it was lower for Hispanic patients.
- Black and Hispanic patients were more likely to be admitted to the ICU and receive mechanical ventilation compared to White patients.
- Rates of advance care planning were similar across groups, but Black and Hispanic patients were less likely to have a DNR order. Significant differences in the mode of death were observed, with Black and Hispanic decedents more likely to receive maximal life support.
Conclusions:
- Hospitalized Black and Hispanic COVID-19 patients experienced greater treatment intensity than White patients.
- This intensified treatment may have concurrently reduced in-hospital mortality disparities.
- However, it also potentially led to increased burdensome medical interventions for these groups near the end of life.
Background:
Black and Hispanic people are more likely to contract COVID-19, require hospitalization, and die than White people due to differences in exposures, comorbidity risk, and healthcare access.
Objective:
To examine the association of race and ethnicity with treatment decisions and intensity for patients hospitalized for COVID-19.
Design:
Retrospective cohort analysis of manually abstracted electronic medical records.
Patients:
7,997 patients (62% non-Hispanic White, 16% non-Black Hispanic, and 23% Black) hospitalized for COVID-19 at 135 community hospitals between March and June 2020 MAIN MEASURES: Advance care planning (ACP), do not resuscitate (DNR) orders, intensive care unit (ICU) admission, mechanical ventilation (MV), and in-hospital mortality. Among decedents, we classified the mode of death based on treatment intensity and code status as treatment limitation (no MV/DNR), treatment withdrawal (MV/DNR), maximal life support (MV/no DNR), or other (no MV/no DNR).
Key Results:
Adjusted in-hospital mortality was similar between White (8%) and Black patients (9%, OR=1.1, 95% CI=0.9-1.4, p=0.254), and lower among Hispanic patients (6%, OR=0.7, 95% CI=0.6-1.0, p=0.032). Black and Hispanic patients were significantly more likely to be treated in the ICU (White 23%, Hispanic 27%, Black 28%) and to receive mechanical ventilation (White 12%, Hispanic 17%, Black 16%). The groups had similar rates of ACP (White 12%, Hispanic 12%, Black 11%), but Black and Hispanic patients were less likely to have a DNR order (White 13%, Hispanic 8%, Black 7%). Among decedents, there were significant differences in mode of death by race/ethnicity (treatment limitation: White 39%, Hispanic 17% (p=0.001), Black 18% (p<0.0001); treatment withdrawal: White 26%, Hispanic 43% (p=0.002), Black 28% (p=0.542); and maximal life support: White 21%, Hispanic 26% (p=0.308), Black 36% (p<0.0001)).
Conclusions:
Hospitalized Black and Hispanic COVID-19 patients received greater treatment intensity than White patients. This may have simultaneously mitigated disparities in in-hospital mortality while increasing burdensome treatment near death.
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