Racial Disparities in Primary Care and Utilization of Health Services at the End-of-Life

1. Racial Disparities in Primary Care and Utilization of Health Services at the End-of-Life Andrea Kronman, MD Boston University School of Medicine

2. Background • End-of-life care 6 % of Medicare beneficiaries die each year Decedents use 30 % of Medicare revenues Under-treatment of symptoms, especially pain Over-treatment with ineffective / unwanted procedures • Role of primary care at end of life ? More likely to elicit patients’ wishes ? • Racial differences Minorities less likely to have advance directives Minorities more likely to die in hospital

3. Hospital Days at End Of Life Minority Status ? Less hospice Less advance directives Different patient preferences Different primary care use

4. Study Objective Examine role of primary care in racial differences of hospital days at the end of life Race / Ethnicity Differences Primary Care Hospital Days End Of Life

5. Methods • Study Sample • 140,000 Medicare decedents July - December 2001 • National, stratified random sample of 1 million beneficiaries • Minorities over-sampled: Black, Hispanic • > 66 years old, continuous Medicare A & B , no ESRD • Study Design • Retrospective database analysis of Medicare decedents during their last 18 months of life 12 months 6 months Death Utilization Variables Primary Care Variables Covariates

6. Measures 12 months 6 months death primary care hospital days covariates • Primary Care (Independent Variables) • Number of primary care visits • Ambulatory Care Sensitive Conditions (ACSC) admissions Utilization (Dependent Variable) • Total hospital days

7. Analysis 12 months 6 months death primary care hospital days covariates • Chi-Square and ANOVA • Multivariate Linear Regression • Covariates • demographics (age, gender, Medicaid as income proxy) • nursing home use • comorbidity ( DxCG prospective risk adjustment score) • geographic location (county)

8. Decedent Characteristics Health Care Utilization

9. Primary Care Visits Predict Fewer Total Hospital Days At End of Life* * Adjusted for all covariates

10. Admission for ACSC Predicts More Hospital Days At End of Life * * Adjusted for all covariates

11. Racial DifferencesVisits to Primary Care Physician p < .01

12. Racial Differences Admission Rates* for Chronic ACSC p < .01 *# of admissions for this diagnosis / 100 people with the diagnosis

13. Racial DifferencesTotal Hospital Days at End-of-Life Model 1: Adjusts for demographics and illness burden Model 2: Model 1 + county

14. Primary Care Mediates Racial Differences in Hospital Days Hospital Days* Model 2: Adjusts for all covariates Model 3: Model 3 + primary care variables *All p < .01

15. Conclusions Primary Care Preceding the End of Life: • Blacks and Hispanics • fewer primary care physician visits • less access to quality primary care End-Of-Life Utilization: • Blacks and Hispanics used more hospital days • partially explained by differences in preceding primary care use

16. Implications Increasing primary care at the end of life could: • Decrease expenditures by decreasing costly hospital days • Improve quality of care, particularly for Blacks and Hispanics

17. Acknowledgements • Arlene Ash, PhD • Karen Freund, MD, MPH • Jim Burgess, PhD • Jenn Fonda, MA