Department of Community Health, Center for Gerontology and Health Care Research, Brown University, Providence, RI 02912, USA.
Gerontologist. 2011 Apr;51(2):251-60. doi: 10.1093/geront/gnq093. Epub 2010 Nov 12.
Medicare hospice is a valuable source of quality care at the end of life, but its lower use by racial minority groups is of concern. This study identifies factors associated with hospice use among urban Black and White nursing home (NH) decedents in the United States.
Multiple data sources are combined and multilevel logistic regression is utilized to examine hospice use among urban Black and White NH residents who had access to hospice and died in 2006 (N = 288,202).
In NHs, Blacks are less likely to use hospice than Whites (35.4% vs. 39.3%), even when controlling for covariates, interactions, and clustering of decedents in NHs and counties (adjusted odds ratio = 0.81, 95% confidence interval = 0.77-0.86). Variation in hospice use is greater among subgroups of Blacks than between Blacks and Whites, and these variations are predominantly due to individual-level factors, with some influence of NH-level factors. Hospice use is higher for Blacks versus Whites with do-not-resuscitate orders and lower for Blacks versus Whites with congestive heart failure (CHF). Additionally, hospice use is greater among Blacks with versus without do-not-resuscitate or do-not-hospitalize orders or cancer and those in low-tier versus other NHs. There was also lower hospice use among Blacks with versus without CHF.
Efforts to reduce racial differences in hospice use should attend to individual-level factors. Heightening use of advance directives and targeting Blacks with CHF for hospice could be particularly helpful.
医疗保险临终关怀是生命末期高质量护理的宝贵资源，但少数族裔群体对其利用率较低令人担忧。本研究旨在确定美国城市黑人和白人养老院（NH）逝者中与临终关怀使用相关的因素。
综合利用多个数据源，采用多水平逻辑回归分析方法，调查了有资格接受临终关怀且于 2006 年去世的城市黑人和白人 NH 居民（N=288202 人）的临终关怀使用情况。
在 NH 中，黑人使用临终关怀的比例低于白人（35.4%比 39.3%），即使在控制了协变量、交互作用以及 NH 和县级逝者的聚类因素后（调整后的优势比=0.81，95%置信区间=0.77-0.86）。与黑人群体内部相比，黑人群体与白人群体之间的临终关怀使用差异更大，而且这些差异主要归因于个体层面的因素，同时也受到 NH 层面因素的一定影响。与白人相比，有“不复苏”医嘱的黑人更有可能使用临终关怀，而患有充血性心力衰竭（CHF）的黑人则不太可能使用临终关怀。此外，与无“不复苏”或“不住院”医嘱或癌症的黑人相比，有这些医嘱的黑人更有可能使用临终关怀，与在其他 NH 中的黑人相比，在低层级 NH 中的黑人更有可能使用临终关怀。此外，与无 CHF 的黑人相比，患有 CHF 的黑人临终关怀的使用率更低。
减少临终关怀使用中的种族差异的努力应该关注个体层面的因素。提高预立医嘱的使用率，并针对患有 CHF 的黑人推广临终关怀，可能会特别有帮助。
