Asian American Medicare Beneficiaries Disproportionately Receive Invasive Mechanical Ventilation When Hospitalized at the End-of-Life

Abstract

Background: Asian Americans are the fastest-growing ethnic minority in the USA, but we know little about the end-of-life care for this population.

Objective: Compare invasive mechanical ventilation (IMV) use between older Asian and White decedents with hospitalization in the last 30 days of life.

Design: Population-based retrospective cohort study.

Participants: A 20% random sample of 2000-2017 Medicare fee-for-service decedents who were 66 years or older and had a hospitalization in the last 30 days of life.

Exposure: White and Asian ethnicity as collected by the Social Security Administration.

Main measures: We identified IMV using validated procedural codes. We compared IMV use between Asian and White fee-for-service decedents using random-effects logistic regression analysis, adjusting for sociodemographics, admitting diagnosis, comorbidities, and secular trends.

Key results: From 2000 to 2017, we identified 2.1 million White (54.5% female, 82.4±8.1 mean age) and 28,328 Asian (50.8% female, 82.6±8.1 mean age) Medicare fee-for-service decedents hospitalized in the last 30 days. Compared to White decedents, Asian fee-for-service decedents have an increased adjusted odds ratio (AOR) of 1.42 (95%CI: 1.38-1.47) for IMV. In sub-analyses, Asians' AOR for IMV differed by admitting diagnoses (cancer AOR=1.32, 95%CI: 1.15-1.51; congestive heart failure AOR=1.75, 95%CI: 1.47-2.08; dementia AOR=1.93, 95%CI: 1.70-2.20; and chronic obstructive pulmonary disease AOR=2.25, 95%CI: 1.76-2.89).

Conclusions: Compared to White decedents, Asian Medicare decedents are more likely to receive IMV when hospitalized at the end-of-life, especially among patients with non-cancer admitting diagnoses. Future research to better understand the reasons for these differences and perceived quality of end-of-life care among Asian Americans is urgently needed.

Keywords: Asian; disparities; end-of-life; geriatric; ventilation.

Figure 1

IMV use at the end of life for hospitalized Asian and White Medicare fee-for-service from 2000 to 2017 and MA decedents from 2011 to 2017. Overall, 16.3% of White fee-for-service (solid black line), 25.9% of Asian fee-for-service (dashed black line), 19.9% White Medicare Advantage (solid grey line), and 28.1% Asian Medicare Advantage (dashed grey line) decedents received IMV. There was an increase in the proportion of White fee-for-service (15.2 to 19.2%), Asian fee-for-service (25.0 to 26.5%), White Medicare Advantage (19.3 to 20.7%), and Asian Medicare Advantage (27.9 to 28.5%) decedents receiving IMV from 2000 to 2017. Abbreviations: IMV, invasive mechanical ventilation.

Figure 2

Forest plot showing the adjusted odds ratio of hospitalized Asian Medicare Advantage and Fee-for-Service beneficiaries for IMV at the EOL, by admitting diagnosis and Medicare plan. Comparison to White beneficiaries is denoted by the black vertical line corresponding to an adjusted odds ratio of 1.00. Each odds ratio is derived from a random-effects logistic regression model adjusting for age, sex, admitting diagnosis, comorbidities, and secular trends. Adjusted odds ratio for Medicare Advantage decedents also accounted for Medicaid-eligibility. Abbreviations: IMV, invasive mechanical ventilation; EOL, end-of-life; and CI, confidence interval.

Figure 3

Among White and Asian decedents hospitalized at the EOL, in-hospital death, ICU/CCU admission, hospice use, and healthcare transitions in the last 3 days by Medicare plan. Abbreviations: EOL, end-of-life; ICU, intensive care unit; and CCU, cardiac care unit.