Racial disparities in nursing homes have been reported for a number of outcomes, including pressure ulcers, influenza vaccination rates, pain management, hospice use and in-hospital death.(16
) Our findings confirm that compared to Whites, Black residents experience more aggressive EOL care with higher rates of in-hospital deaths and lower rates of hospice use. Having observed these overall large racial differences, we examined whether racial disparities in these outcomes are the result of differential within-facility treatments and/or of across-facility variations.
Based on the changes in the odds ratios for race, we show that demographic and health characteristics explain a very small portion of the observed racial differences in each outcome. However, feeding tubes and DNR and DNH orders account for significant proportions of racial differences in in-hospital deaths and hospice use. These findings are consistent with the literature reporting that African-Americans are less likely to have documented advance directives, including DNR and DNH orders.(39
) The lower prevalence of DNR and DNH orders in this population may be a reflection of their overall preferences for more aggressive and curative medical treatments.(40
) It could also be the result of poor or lacking communication between nursing home staff and residents/families regarding advanced care planning, thus reflecting perhaps an incomplete understanding of the inherent risks and benefits associated with aggressive treatments, such as hospitalization, at the EOL.(44
) Research needs to further explore why Black residents are less likely to have a DNR or a DNH order.
For the two outcomes of interest we find no within-facility racial disparities, i.e. Black residents are no more likely to die in hospitals or less likely to use hospice than White residents in the same facilities. Cai et al. found that the risk of pressure ulcers is not different between Black and White residents in the same facilities.(17
) Our findings further suggest that even for the more complex decision making processes, such as those at the EOL, which tend to involve multiple parties (e.g. nurses, directors of nursing, medical directors, hospice personnel), nursing homes do not tend to systematically treat Black residents differently from White residents residing in the same facility.
The findings also suggest that the primary source of the observed racial differences in EOL care outcomes is due to the across-facility variations. Other conditions being equal, residents from facilities with higher concentration of Blacks have higher risk of in-hospital death and lower probability of using hospice. One plausible reason could be that these facilities provide overall poorer quality of EOL care. This is supported by a recent study demonstrating that residents from predominantly Black facilities are at high risk of pressure ulcers, ceteris paribus.(17
) Therefore, it may be important to address issues impacting the overall quality of care in facilities where Black residents tend to congregate. For example, nursing homes with large proportions of Black residents are more likely to derive their revenues from Medicaid which reimburses nursing homes at a lower rate than Medicare or private funds. (17
) Some have suggested that Medicaid pay-for-performance strategies, by providing additional resources and financial incentives for improving care quality, may be useful in also eliminating the across facility racial disparities.(17
) However, none of the current state programs with Medicaid pay-for-performance in nursing homes focus on care provided to EOL residents. (46
) The Centers for Medicare and Medicaid Services (CMS) routinely evaluate and publish quality of care in nursing homes using 19 quality indicators, as a market-based strategy for quality improvement. Yet, none of these quality measures specifically focus on quality of EOL care. Risk-adjusted EOL quality measures based on the MDS data are presently under development.(48
) If these measures prove valid and become part of the CMS nursing home report cards, they may provide an opportunity for bridging the gap in EOL quality of care across-facilities. But such report cards alone may not be sufficient to improve care quality and they may need to be paired with other incentives, such as the pay-for-performance programs.
The rate of potentially avoidable hospitalizations (including congestive heart failure, COPD, urinary tract infection) is one performance measure employed by the Medicare Nursing Home Value-Based Purchasing Demonstration (NHVBP).(49
) Under the NHVBP, CMS will reward nursing homes if their performance measures rank in the top 20 percentile or if they are in the top 20 percentile in terms of improvement in their performance measures. If the NHVBP can incentivize nursing homes to reduce hospitalizations, all residents, including those at the EOL, may benefit. Specifically, nursing homes which tend to hospitalize more residents may be incentivized to reduce hospitalizations due to the expected reward for performance improvement. As a result, the across-facility variations in in-hospital death may be reduced, which may reduce racial disparities in this measure.
Alternatively, more frequent in-hospital death and lower hospice utilization in Black-dominated facilities could be the reflection of preferences at aggregate level. The “treatment norm” in these facilities may be determined by the common preferences of the vast majority. Consequently, Blacks in these facilities may simply be receiving the type and level of care that is in accordance with their preferences for aggressive care. However, whether White residents in these facilities receive the care at the level of aggressiveness that they prefer is unclear. More research is necessary to evaluate the care provided to end-of-life residents in predominantly Black-nursing homes.
There are several limitations to the current study. First, our study is based exclusively on New York State facilities. Therefore, generalizing from our findings to other states should be done with caution. Second, we only focus on two EOL care outcomes—in-hospital death and hospice use. For other outcomes, patterns of racial differences with regard to within and across facility variations may be different. Furthermore, although we provide several plausible reasons for the across-facility variations, future studies are needed to further investigate the differences between facilities that are predominantly Black versus those that are predominantly White.
In conclusion, we find that several factors, including Black residents’ higher use of feeding tubes and lower use of documented DNR and DNH orders, partially contribute to racial differences in in-hospital deaths and hospice use. The remaining racial disparities are primarily related to the overall EOL care practices in facilities with higher proportions of Black residents, not to differential hospitalization and hospice referral patterns within facilities.