Advance Directive Completion Among Black Adults Within a Community-Based Integrated Health Care System

ObjectivesThe study was conducted to estimate the prevalence of advance directive (AD) completion among Black adults vs non-Hispanic White adults within Kaiser Permanente Northern California integrated health system that includes access to outpatient advance care planning (ACP) specialists and to identify medical services utilization patterns and societal factors that could influence ACP engagement. DesignThe study was carried out through retrospective analysis of electronic health record data of active Kaiser Permanente Northern California members from January 1, 2013 to December 31, 2017, who were age 55 and older, and represented 572,466 active members, of which 11.7% were Black adults. The primary objective was AD completion comparing Black adults to non-Hispanic White adults. Demographic data included age, sex, comorbidities (Charlson comorbidity score ≥ 3) and medical services utilization (inpatient, outpatient, and emergency department [ED] use). Sociodemographic data derived from census data that include census block demographics and head of household educational attainment were utilized. ResultsBlack adults were younger, but had a higher burden of comorbidities (Charlson comorbidity score ≥ 3, 25.3% vs 19.3%) and were more likely to have multiple ED visits (6.7% vs 3.3%) compared to non-Hispanic White adults. The crude AD completion rate was lower among Black adults (10.0% vs 20.3%), and after adjusting for age and health system service area, the difference remained largely unchanged (11.7% vs 20.3%) compared to non-Hispanic White adults. ConclusionsAmong Kaiser Permanente Northern California members with access to outpatient ACP specialists, Black adults were only half as likely to complete an AD. This disparity was only slightly attenuated when standardized for age and health system service area. In addition, Black adults were also less likely to use outpatient services and more likely to use ED services.