title: Racial disparities in in-hospital death and hospice use among nursing home residents at the end of life.
abstract: BACKGROUND
  Significant racial disparities have been reported regarding nursing home residents' use of hospital and hospice care at the end of life (EOL).
  
  
  OBJECTIVE
  To examine whether the observed racial disparities in EOL care are due to within-facility or across-facility variations.
  
  
  METHODS
  Cross-sectional study of 49,048 long-term care residents (9.23% black and 90.77% white) in 555 New York State nursing homes who died during 2005-2007. The Minimum Data Set was linked with Medicare inpatient and hospice claims.
  
  
  METHODS
  In-hospital death determined by inpatient claims and hospice use determined by hospice claims. For each outcome, risk factors were added sequentially to examine their partial effects on the racial differences. Hierarchical models were fit to test whether racial disparities are due to within-facility or across-facility variations.
  
  
  RESULTS
  40.33% of blacks and 24.07% of whites died in hospitals; 11.55% of blacks and 17.39% of whites used hospice. These differences are partially due to disparate use of feeding tubes, do-not-resuscitate and do-not-hospitalize orders. We find no racial disparities in in-hospital death [odds ratio (OR) of race=0.95; 95% confidence interval (CI), 0.87-1.04] or hospice use (OR of race=0.90, 95% CI, 0.79-1.02) within same facilities. Living in facilities with 10% more blacks increases the odds of in-hospital death by 22% (OR=1.22, 95% CI, 1.17-1.26) and decreases the odds of hospice use by 15% (OR=0.85, 95% CI, 0.78-0.94).
  
  
  CONCLUSIONS
  Differential use of feeding tubes, do-not-resuscitate and do-not-hospitalize orders lead to racial differences in in-hospital death and hospice use. The remaining disparities are primarily due to overall EOL care practices in predominately black facilities, not to differential hospitalization and hospice-referral patterns within facilities.
authors: Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA. Nan_Zheng@urmc.rochester.edu
authors: Nan Tracy
authors: NT
authors: Zheng
authors: Dana B
authors: DB
authors: Mukamel
authors: Thomas
authors: T
authors: Caprio
authors: Shubing
authors: S
authors: Cai
authors: Helena
authors: H
authors: Temkin-Greener
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D044383:Black People / Q000706:statistics & numerical data; D016001:Confidence Intervals; D003430:Cross-Sectional Studies; D004750:Enteral Nutrition / Q000706:statistics & numerical data; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D017051:Hospice Care / Q000706:statistics & numerical data*; D017052:Hospital Mortality; D006801:Humans; D016015:Logistic Models; D008297:Male; D009518:New York / Q000453:epidemiology; D009735:Nursing Homes / Q000706:statistics & numerical data; D016017:Odds Ratio; D044469:Racial Groups / Q000706:statistics & numerical data*; D016414:Resuscitation Orders; D012307:Risk Factors; D013727:Terminal Care / Q000706:statistics & numerical data*; D044465:White People / Q000706:statistics & numerical data; D001741:Black or African American