Racial and ethnic differences in the treatment of seriously ill patients: A comparison of African-American, Caucasian and Hispanic Veterans

Background: No national data exist regarding racial/ethnic differences in the use of interventions for patients at the end of life. Objectives: 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. Design: Retrospective cohort study during fiscal years 1991-2002. Patients: Hospitalized veterans >55 years, defined clinically as at high-risk for 6-month mortality, not by decedent data. Measurements: 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. Results: 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≤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. Conclusions: 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.