Racial and Ethnic Differences in Informal and Formal Advance Care Planning Among U.S. Older Adults

Lenko, Rachel; Voepel‐Lewis, Terri; Robinson‐Lane, Sheria G.; Hoffman, Geoffrey J.

doi:10.1177/08982643221104926

Cited by 12 publications

(9 citation statements)

References 61 publications

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“…A recent systematic review examined disparities in ACP documentation and found significant differences in rates of completed advanced directives between non‐Hispanic White patients and non‐Hispanic Black patients 11 . Consistent with our findings, other retrospective studies have shown that non‐Hispanic White patients were more likely to have ACP discussions than Latino or African‐American patients 22 . Although recent interventions have utilized EHR‐based tools to improve overall ACP documentation, it is unknown whether these tools were equally applied across various populations as these studies did not stratify their results by race or ethnicity 16,23,24 .…”

Section: Discussionsupporting

confidence: 89%

“…11 Consistent with our findings, other retrospective studies have shown that non-Hispanic White patients were more likely to have ACP discussions than Latino or African-American patients. 22 Although recent interventions have utilized EHR-based tools to improve overall ACP documentation, it is unknown whether these tools were equally applied across various populations as these studies did not stratify their results by race or ethnicity. 16,23,24 In contrast to other literature, our study uniquely evaluated the disparate impact of an intervention to improve accessible ACP documentation on patients by race and ethnicity.…”

Section: Discussionmentioning

confidence: 99%

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Across race, ethnicity, and language: An intervention to improve advance care planning documentation unmasks health disparities

Dutta,

Flynn,

Oreper

et al. 2023

Journal of Hospital Medicine

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BackgroundRacial and ethnic minority groups are less likely to have advance directives and living wills, despite the importance of advanced care planning (ACP) in end‐of‐life care. We aimed to understand the impact of an intervention to improve ACP documentation across race, ethnicity, and language on hospitalized patients at our institution.MethodsWe launched an intervention to improve the rates of ACP documentation for hospitalized patients aged >75 or with advanced illness defined by the International Classification of Diseases 10th Revision codes. We analyzed ACP completion rates, preintervention, and intervention, and used interrupted time‐series analyses to measure the differential impact of the intervention across race, ethnicity, and language.Key ResultsA total of 10,220 patients met the inclusion criteria. Overall rates of ACP documentation improved from 13.9% to 43.7% in the intervention period, with a 2.47% monthly increase in ACP documentation compared to baseline (p < .001). During the intervention period, the rate of ACP documentation increased by 2.72% per month for non‐Hispanic White patients (p < .001), by 1.84% per month for Latinx patients (p < .001), and by 1.9% per month for Black patients (p < .001). Differences in the intervention trends between non‐Hispanic White and Latinx patients (p = .04) and Black patients (p = .04) were significant.ConclusionsAn intervention designed to improve ACP documentation in hospitalized patients widened a disparity across race and ethnicity with Latinx and Black patients having lower rates of improvement. Our findings reinforce the need to measure the impact of quality improvement interventions on existing health disparities and to implement specific strategies to prevent worsening disparities.

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Section: Discussionsupporting

confidence: 89%

Section: Discussionmentioning

confidence: 99%

Across race, ethnicity, and language: An intervention to improve advance care planning documentation unmasks health disparities

Dutta,

Flynn,

Oreper

et al. 2023

Journal of Hospital Medicine

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“…Preoperative LST documentation rates were significantly lower for Black patients, Hispanic patients, and patients identifying as other (ie, American Indian or Alaskan Native, Asian, Native Hawaiian, or Other Pacific Islander) than for White patients. Although our study focuses on patients undergoing surgical procedures, racial and ethnic disparities in GOC planning have been reported in other studies . Rurality of residence also suggests cultural differences on an individual basis.…”

Section: Discussionmentioning

confidence: 83%

Disparities in Preoperative Goals of Care Documentation in Veterans

Wu,

Giannitrapani,

Garcia

et al. 2023

JAMA Netw Open

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ImportancePreoperative goals of care discussion and documentation are important for patients undergoing surgery, a major health care stressor that incurs risk.ObjectiveTo assess the association of race, ethnicity, and other factors, including history of mental health disability, with disparities in preoperative goals of care documentation among veterans.Design, Setting, and ParticipantsThis retrospective cross-sectional study assessed data from the Veterans Healthcare Administration (VHA) of 229 737 veterans who underwent surgical procedures between January 1, 2017, and October 18, 2022.ExposuresPatient-level (ie, race, ethnicity, medical comorbidities, history of mental health comorbidity) and system-level (ie, facility complexity level) factors.Main Outcomes and MeasuresPreoperative life-sustaining treatment (LST) note documentation or no LST note documentation within 30 days prior to or on day of surgery. The standardized mean differences were calculated to assess the magnitude of differences between groups. Odds ratios (ORs) and 95% CIs were estimated with logistic regression.ResultsIn this study, 13 408 patients (5.8%) completed preoperative LST from 229 737 VHA patients (209 123 [91.0%] male; 20 614 [9.0%] female; mean [SD] age, 65.5 [11.9] years) who received surgery. Compared with patients who did complete preoperative LST, patients tended to complete preoperative documentation less often if they were female (19 914 [9.2%] vs 700 [5.2%]), Black individuals (42 571 [19.7%] vs 2416 [18.0%]), Hispanic individuals (11 793 [5.5%] vs 631 [4.7%]), or from rural areas (75 637 [35.0%] vs 4273 [31.9%]); had a history of mental health disability (65 974 [30.5%] vs 4053 [30.2%]); or were seen at lowest-complexity (ie, level 3) facilities (7849 [3.6%] vs 78 [0.6%]). Over time, despite the COVID-19 pandemic, patients undergoing surgical procedures completed preoperative LST increasingly more often. Covariate-adjusted estimates of preoperative LST completion demonstrated that patients of racial or ethnic minority background (Black patients: OR, 0.79; 95% CI, 0.77-0.80; P &lt;.001; patients selecting other race: OR, 0.78; 95% CI, 0.74-0.81; P &lt;.001; Hispanic patients: OR, 0.78; 95% CI, 0.76-0.81; P &lt;.001) and patients from rural regions (OR, 0.91; 95% CI, 0.90-0.93; P &lt;.001) had lower likelihoods of completing LST compared with patients who were White or non-Hispanic and patients from urban areas. Patients with any mental health disability history also had lower likelihood of completing preoperative LST than those without a history (OR, 0.93; 95% CI, 0.92-0.94; P = .001).Conclusions and RelevanceIn this cross-sectional study, disparities in documentation rates within a VHA cohort persisted based on race, ethnicity, rurality of patient residence, history of mental health disability, and access to high-volume, high-complexity facilities.

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“…Over recent years there has been an increased focus on these disparities, catalysed by factors including the Black Lives Matter movement [12] and the unequal number of deaths during the Covid-19 pandemic [13,14]. Many studies internationally indicate some degree of disparity in rates of ACP related to ethnicity [15][16][17]. Evidence from the USA suggests that White patients have higher rates of hospice use, and formal ACP documentation and/or "do not attempt cardiopulmonary resuscitation" (DNACPR) statements compared with people from other ethnic groups [18][19][20].…”

Section: Race Ethnicity and Acpmentioning

confidence: 99%

How does ethnicity affect presence of advance care planning in care records for individuals with advanced disease? A mixed-methods systematic review

Crooks¹,

Trotter

OBE³

et al. 2023

BMC Palliat Care

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Background Advance care planning (ACP) is the process supporting individuals with life-limiting illness to make informed decisions about their future healthcare. Ethnic disparities in ACP have been widely highlighted, but interpretation is challenging due to methodological heterogeneity. This review aims to examine differences in the presence of documented ACP in individuals’ care records for people with advanced disease by ethnic group, and identify patient and clinician related factors contributing to this. Methods Mixed-methods systematic review. Keyword searches on six electronic databases were conducted (01/2000–04/2022). The primary outcome measure was statistically significant differences in the presence of ACP in patients’ care records by ethnicity: quantitative data was summarised and tabulated. The secondary outcome measures were patient and clinician-based factors affecting ACP. Data was analysed qualitatively through thematic analysis; themes were developed and presented in a narrative synthesis. Feedback on themes was gained from Patient and Public Involvement (PPI) representatives. Study quality was assessed through Joanna Briggs Institute Critical Appraisal tools and Gough’s Weight of Evidence. Results N=35 papers were included in total; all had Medium/High Weight of Evidence. Fifteen papers (comparing two or more ethnic groups) addressed the primary outcome measure. Twelve of the fifteen papers reported White patients had statistically higher rates of formally documented ACP in their care records than patients from other ethnic groups. There were no significant differences in the presence of informal ACP between ethnic groups. Nineteen papers addressed the secondary outcome measure; thirteen discussed patient-based factors impacting ACP presence with four key themes: poor awareness and understanding of ACP; financial constraints; faith and religion; and family involvement. Eight papers discussed clinician-based factors with three key themes: poor clinician confidence around cultural values and ideals; exacerbation of institutional constraints; and pre-conceived ideas of patients’ wishes. Conclusions This review found differences in the presence of legal ACP across ethnic groups despite similar presence of informal end of life conversations. Factors including low clinician confidence to deliver culturally sensitive, individualised conversations around ACP, and patients reasons for not wishing to engage in ACP (including, faith, religion or family preferences) may begin to explain some documented differences. Trial registration PROSPERO-CRD42022315252.

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Racial and Ethnic Differences in Informal and Formal Advance Care Planning Among U.S. Older Adults

Cited by 12 publications

References 61 publications

Across race, ethnicity, and language: An intervention to improve advance care planning documentation unmasks health disparities

Across race, ethnicity, and language: An intervention to improve advance care planning documentation unmasks health disparities

Disparities in Preoperative Goals of Care Documentation in Veterans

How does ethnicity affect presence of advance care planning in care records for individuals with advanced disease? A mixed-methods systematic review

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