Racial variation in end-of-life intensive care use: A race or hospital effect?

Objective. To determine if racial and ethnic variations exist in intensive care (ICU) use during terminal hospitalizations, and, if variations do exist, to determine whether they can be explained by systematic differences in hospital utilization by race/ethnicity. Data Source. 1999 hospital discharge data from all nonfederal hospitals in Florida, Massachusetts, New Jersey, New York, and Virginia. Design. We identified all terminal admissions (N=192,705) among adults. We calculated crude rates of ICU use among non-Hispanic whites, blacks, Hispanics, and those with "other" race/ethnicity. We performed multivariable logistic regression on ICU use, with and without adjustment for clustering of patients within hospitals, to calculate adjusted differences in ICU use and by race/ethnicity. We explored both a random-effects (RE) and fixed-effect (FE) specification to adjust for hospital-level clustering. Data Collection. The data were collected by each state. Principal Findings. ICU use during the terminal hospitalization was highest among nonwhites, varying from 64.4 percent among Hispanics to 57.5 percent among whites. Compared to white women, the risk-adjusted odds of ICU use was higher for white men and for nonwhites of both sexes (odds ratios [ORs] and 95 percent confidence intervals: white men =1.16 (1.14-1.19), black men =1.35 (1.17-1.56), Hispanic men =1.52 (1.27-1.82), black women =1.31 (1.25-1.37), Hispanic women =1.53 (1.43-1.63)). Additional adjustment for within-hospital clustering of patients using the RE model did not change the estimate for white men, but markedly attenuated observed differences for blacks (OR for men =1.12 (0.96-1.31), women =1.10 (1.03-1.17)) and Hispanics (OR for men =1.19 (1.00-1.42), women =1.18 (1.09-1.27)). Results from the FE model were similar to the RE model (OR for black men =1.10 (0.95-1.28), black women =1.07 (1.02-1.13) Hispanic men =1.17 (0.96-1.42), and Hispanic women =1.14 (1.06-1.24)) Conclusions. The majority of observed differences in terminal ICU use among blacks and Hispanics were attributable to their use of hospitals with higher ICU use rather than to racial differences in ICU use within the same hospital.