African-American and Hispanic Medicare beneficiaries with heart failure appear less likely to receive hospice care than white patients with the same condition, according to a report in the March 8 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
"Underuse of hospice care is well documented, especially among racial and ethnic minorities," the authors write as background information in the article. "Racial and ethnic differences in patients who use hospice care have been found across a spectrum of patients with cancer diagnoses and may be more pronounced in patients with non-cancer diagnoses." Heart failure affects nearly 5 million people in the United States; advanced heart disease is the second most common hospice diagnosis, accounting for about 12 percent of all hospice enrollees.
Jane L. Givens, M.D., M.S.C.E., of the Hebrew SeniorLife Institute for Aging Research, Beth Israel Deaconess Medical Center, Boston, and colleagues studied a national sample of 98,258 Medicare beneficiaries age 66 or older who had a diagnosis of heart failure. None of the participants was enrolled in hospice at the beginning of the study, in 2000.
Over the next year, of the beneficiaries who entered hospice care, 18.2 percent did so because of heart failure. In unadjusted analyses, black and Hispanic patients were less likely than white patients to enter hospice care; the association persisted after adjusting for other factors, including income, urban location, severity of heart failure and co-occurring illnesses. When compared with whites, black patients and Hispanic patients had lower odds of receiving hospice care.
"In addition to sociodemographic, clinical and geographic characteristics, cultural beliefs and values may contribute to differences between blacks and whites in end-of-life care and hospice use," the authors write. "For example, compared with whites, blacks are less likely to complete advance directives, have less favorable beliefs about hospice care, opt for more aggressive treatments and are more likely to have spiritual beliefs that conflict with the goals of palliative treatment."
"In addition, lack of trust between patients and physicians may be more pronounced for ethnic minorities and may contribute to ethnic differences in hospice entry," the authors conclude. "It is not clear how many of these differences reflect access issues as opposed to considered patient preferences."
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