Racial Differences in Hospitalizations of Dying Medicare-Medicaid Dually Eligible Nursing Home Residents

Abstract

Objectives: To examine whether racial differences in end-of-life (EOL) hospitalizations vary according to the presence of advance directives, specifically do-not-hospitalize (DNH) orders, and individual cognitive status in nursing home (NH) residents.

Design: National data, including Medicare data and Minimum Data Set (MDS) 2.0, between January 1, 2007, and September 30, 2010, were linked. EOL hospitalizations were hospitalizations in the last 30 days of life. Linear probability models with an interaction term (between race and DNH) and NH fixed-effects were estimated. The analyses were stratified according to cognitive status.

Setting: Nursing homes in the United States.

Participants: Dually eligible Medicare-Medicaid decedents enrolled in Medicare fee-for-service plans and long-stay NH residents (in NHs ≥ 90 days before death) (N = 394,948).

Measurements: Racial difference in EOL hospitalizations from a NH.

Results: End-of-life hospitalization rate was 31.7% for whites and 42.8% for blacks. For participants without DNH orders, adjusted probability of EOL hospitalization was higher for blacks than for whites: 2.7 percentage points in those with moderate cognitive impairment (P < .001) and 4.7 percentage points in those with severe cognitive impairment (P < .001). For those with DNH orders, adjusted racial differences in EOL hospitalization were not statistically significant in those with moderate (P = .25) or severe (P = .93) cognitive impairment, but blacks had a higher probability of EOL hospitalization than whites if they had relatively intact cognitive status.

Conclusion: Racial differences in EOL hospitalization varied with DNH orders and cognitive status in dying residents. Future research is necessary to understand the reasons behind these variations.

Keywords: end-of-life hospitalization; nursing homes; racial differences.

Figure 1

Adjusted overall racial differences (black-white) in the probabilities of EOL hospitalizations by cognitive status and the presence of DNH (based on the regression results presented in table 2) Numbers in parentheses represent standard errors. The vertical axis indicates the differences in the adjusted probabilities of EOL hospitalizations between black and white residents. The positive difference indicates that the adjusted probability of EOL hospitalization is higher for blacks than for whites. *** p<0.01, ** p<0.05, * p<0.1 For each subgroup, the statistical differences between “No DNH” bar and “DNH” bar were captured by the significance level of the interaction term in Table 2.