Braun Ursula K, McCullough Laurence B, Beyth Rebecca J, Wray Nelda P, Kunik Mark E, Morgan Robert O
Michael E. DeBakey VA Medical Center, Section of Health Services Research, Houston Center for Quality of Care & Utilization Studies, USA.
J Natl Med Assoc. 2008 Sep;100(9):1041-51. doi: 10.1016/s0027-9684(15)31442-5.
No national data exist regarding racial/ethnic differences in the use of interventions for patients at the end of life.
To test whether among 3 cohorts of hospitalized seriously ill veterans with cancer, noncancer or dementia the use of common life-sustaining treatments differed significantly by race/ethnicity.
Retrospective cohort study during fiscal years 1991-2002.
Hospitalized veterans >55 years, defined clinically as at high-risk for 6-month mortality, not by decedent data.
Utilization patterns by race/ethnicity for 5 life-sustaining therapies. Logistic regression models evaluated differences among Caucasians, African Americans and Hispanics, controlling for age, disease severity and clustering of patients within Veterans Affairs (VA) medical centers.
Among 166,059 veterans, both differences and commonalities across diagnostic cohorts were found. African Americans received more or the same amount of end-of-life treatments across disease cohorts, except for less resuscitation [OR = 0.84 (0.77-0.92), p = 0.002] and mechanical ventilation [OR = 0.89 (0.85-0.94), p < or = 0.0001] in noncancer patients. Hispanics were 36% (cancer) to 55% (noncancer) to 88% (dementia) more likely to receive transfusions than Caucasians (p < 0.0001). They received similar rates as Caucasians for all other interventions in all other groups, except for 161% higher likelihood for mechanical ventilation in patients with dementia. Increased end-of-life treatments for both minority groups were most pronounced in the dementia cohort. Differences demonstrated a strong interaction with the disease cohort.
Differences in level of end-of-life treatments were disease specific and bidirectional for African Americans. In the absence of generally accepted, evidence-based standards for end-of-life care, these differences may or may not constitute disparities.
目前尚无关于临终患者干预措施使用方面种族/民族差异的全国性数据。
检验在三组患有癌症、非癌症或痴呆症的住院重症退伍军人中，常用维持生命治疗的使用在种族/民族方面是否存在显著差异。
1991 - 2002财政年度的回顾性队列研究。
年龄大于55岁的住院退伍军人，临床定义为6个月死亡风险高，而非依据死亡数据。
按种族/民族划分的5种维持生命疗法的使用模式。逻辑回归模型评估了白种人、非裔美国人和西班牙裔之间的差异，并对年龄、疾病严重程度以及退伍军人事务部（VA）医疗中心内患者的聚类情况进行了控制。
在166,059名退伍军人中，各诊断队列之间既存在差异也有共性。除了非癌症患者接受的复苏治疗较少[比值比（OR）= 0.84（0.77 - 0.92），p = 0.002]和机械通气较少[OR = 0.89（0.85 - 0.94），p≤0.0001]外，非裔美国人在各个疾病队列中接受的临终治疗更多或数量相同。西班牙裔接受输血的可能性比白种人高36%（癌症）至55%（非癌症）至88%（痴呆症）（p < 0.0001）。在所有其他组中，他们接受的所有其他干预措施的比例与白种人相似，但痴呆症患者接受机械通气的可能性比白种人高161%。两个少数群体临终治疗的增加在痴呆症队列中最为明显。差异显示与疾病队列有强烈的相互作用。
临终治疗水平的差异因疾病而异，对非裔美国人来说是双向的。在缺乏普遍接受的、基于证据的临终护理标准的情况下，这些差异可能构成或不构成差异。
