Temkin-Greener Helena, Yan Di, Wang Sijiu, Cai Shubing
Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
J Am Geriatr Soc. 2021 Jul;69(7):1877-1886. doi: 10.1111/jgs.17117. Epub 2021 Mar 22.
Explore within and across nursing home (NH) racial disparities in end-of-life (EOL) hospitalizations for residents with Alzheimer's disease or related dementia (ADRD), and examine whether severe cognitive impairment influences these relationships.
Observational study merging, at the individual level, C2014-2017 national-level Minimum Data Set (MDS), Medicare Beneficiary Summary Files (MBSF), and Medicare Provider Analysis and Review (MedPAR). Nursing Home Compare (NHC) was also used.
Long-stay residents who died in a NH or a hospital within 8 days of discharge.
Analytical sample included 665,033 decedent residents with ADRD in 14,595 facilities.
The outcome was hospitalization within 30 days of death. Key independent variables were race, severe cognitive impairment, and NH-level proportion of black residents. Other covariates included socio-demographics, dual eligibility, hospice enrollment, and chronic conditions. Facility-level characteristics were also included (e.g. profit status, staffing hours, etc.). We fit linear probability models with robust standard errors, fixed and random effects.
Compared to whites, black decedents had a significantly (p < 0.01) higher risk of EOL hospitalizations (7.88%). Among those with severe cognitive impairment, whites showed a lower risk of hospitalizations (6.04%). But EOL hospitalization risk among blacks with severe cognitive impairment was still significantly elevated (β = 0.0494; p < 0.01). A comparison of the base model with the fixed and random-effects models showed statistically significant hospitalization risk by decedent's race both within and across facilities.
We found disparities between black and white residents with ADRD both within and across facilities. The within-facility disparities may be due to residents' preferences and/or NH practices that contribute to differential treatment. The across facility differences point to the overall quality of care disparities in homes with a higher prevalence of black residents. Persistence of such systemic disparities among the most vulnerable individuals is extremely troubling.
探讨养老院（NH）内及不同养老院中，患有阿尔茨海默病或相关痴呆症（ADRD）的居民在临终（EOL）住院方面的种族差异，并研究严重认知障碍是否会影响这些关系。
一项观察性研究，在个体层面合并2014 - 2017年国家级最低数据集（MDS）、医疗保险受益人汇总文件（MBSF）和医疗保险提供者分析与审查（MedPAR）。还使用了养老院比较（NHC）数据。
在出院后8天内于养老院或医院死亡的长期居住居民。
分析样本包括14595家机构中的665033名患有ADRD的已故居民。
结局是死亡后30天内的住院情况。关键自变量是种族、严重认知障碍以及养老院层面黑人居民的比例。其他协变量包括社会人口统计学特征、双重资格、临终关怀登记情况和慢性病。还包括机构层面的特征（如盈利状况、人员配备时间等）。我们采用了具有稳健标准误、固定效应和随机效应的线性概率模型。
与白人相比，黑人死者临终住院的风险显著更高（p < 0.01）（7.88%）。在患有严重认知障碍的人群中，白人的住院风险较低（6.04%）。但患有严重认知障碍的黑人临终住院风险仍然显著升高（β = 0.0494；p < 0.01）。基础模型与固定效应和随机效应模型的比较表明，在机构内和不同机构间，死者种族导致的住院风险在统计学上均具有显著性。
我们发现，患有ADRD的黑人和白人居民在机构内及不同机构间均存在差异。机构内的差异可能是由于居民的偏好和/或养老院的做法导致了差异化治疗。不同机构间的差异表明，黑人居民患病率较高的养老院在整体护理质量上存在差异。这种系统性差异在最脆弱人群中持续存在，令人极为担忧。
