Race/Ethnicity, Socioeconomic Status, and Healthcare Intensity at the End of Life

Abstract

Background: Although racial/ethnic minorities receive more intense, nonbeneficial healthcare at the end of life, the role of race/ethnicity independent of other social determinants of health is not well understood.

Objectives: Examine the association between race/ethnicity, other key social determinants of health, and healthcare intensity in the last 30 days of life for those with chronic, life-limiting illness.

Subjects: We identified 22,068 decedents with chronic illness cared for at a single healthcare system in Washington State who died between 2010 and 2015 and linked electronic health records to death certificate data.

Design: Binomial regression models were used to test associations of healthcare intensity with race/ethnicity, insurance status, education, and median income by zip code. Path analyses tested direct and indirect effects of race/ethnicity with insurance, education, and median income by zip code used as mediators.

Measurements: We examined three measures of healthcare intensity: (1) intensive care unit admission, (2) use of mechanical ventilation, and (3) receipt of cardiopulmonary resuscitation.

Results: Minority race/ethnicity, lower income and educational attainment, and Medicaid and military insurance were associated with higher intensity care. Socioeconomic disadvantage accounted for some of the higher intensity in racial/ethnic minorities, but most of the effects were direct effects of race/ethnicity.

Conclusions: The effects of minority race/ethnicity on healthcare intensity at the end of life are only partly mediated by other social determinants of health. Future interventions should address the factors driving both direct and indirect effects of race/ethnicity on healthcare intensity.

Keywords: end of life; healthcare disparities; race/ethnicity; social determinants; socioeconomic status.

FIG. 1.

Path model of the influence of race/ethnicity and socioeconomic status on whether any cardiopulmonary resuscitation occurred in the last month of life, with mediation by insurance coverage and the number of chronic comorbidities.

FIG. 2.

Path model of the influence of race/ethnicity and socioeconomic status on whether any mechanical ventilation occurred in the last month of life, with mediation by insurance coverage and the number of chronic comorbidities.

FIG. 3.

Path model of the influence of race/ethnicity and socioeconomic status on ICU care was provided in the last month of life, with mediation by insurance coverage and the number of chronic comorbidities. This model, again, showed nonsignificant misfit to the observed data (p = 0.5893 for the χ² test of fit). The regression coefficients are shown in larger typeface on each path (with p values shown as superscripts). The model was very similar to the model for mechanical ventilation. Patients from racial/ethnic minorities, those with lower education, those living in neighborhoods with lower median income, those covered by military or Medicaid insurance, and those with more chronic diseases were significantly more likely than their counterparts to receive ICU care in the last month of life.