Racial disparity in end-of-life hospitalizations among nursing home residents with dementia

Abstract

Objective: 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.

Design: 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.

Setting: Long-stay residents who died in a NH or a hospital within 8 days of discharge.

Participants: Analytical sample included 665,033 decedent residents with ADRD in 14,595 facilities.

Main outcomes and measures: 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.

Results: 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.

Conclusions and relevance: 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.

Keywords: ADRD; disparities; end-of-life; hospitalizations; nursing home.

Figure 1:

Association of Facility-Level Characteristics with the Proportion of Black Residents Note: Figure shows estimate coefficients and 95%CIs resulting from a facility-level linear regression, with year fixed effects. Dependent variable was the proportion of black residents in a facility. Independent variables included facility characteristics listed in the figure. Values are shown as percentage point changes; for example, for profit facilities were associated with having a 3.43 percentage point higher proportion of black residents than non-profit facilities.