Abstract P92: Racial Differences in End of Life Care in Medicare Beneficiaries With Heart Failure

Abstract

Background: Attention to quality and consistency of care at the end of life has increased over the last decade. However, little is known about racial differences in health care use at the end of life in patients with heart failure, a complex disease with high mortality and morbidity. Methods: We used a 5% national sample of Medicare fee-for-service beneficiaries with heart failure who died from 2000-2007. Demographics included age at death, sex, comorbidities and race (“black” vs. “non-black”). We calculated frequency of all-cause hospitalizations, intensive care unit (ICU) and hospice use in the 180 days preceding death. We calculated total cost to Medicare (in 2007 US dollars). Chi-square and Kruskal-Wallis tests were used to test for differences by race and Cochran-Mantel-Haenzel tests for nonzero correlation were used to test trends. We used generalized linear models with a log link and Poisson distribution to model total costs in the last 6 months of life. Results: The cohort included 229,543 Medicare patients with heart failure who died from 2000-2007. The average age at death was 83 years and 18,141 (7.9%) patients were black. Black patients were more likely than non-black patients to be hospitalized in the last six months of life (86.1% vs 80.7%; p<.001). Among hospitalized patients, blacks had longer lengths of stay (27.6 days vs. 20.3 days; p<.001) and were more likely to spend time in the ICU (51.5% vs 46.6%; p<.001). Black patients were less likely to use hospice services compared to non-blacks (21.9% vs. 28.6%; p<.001). While hospice use among blacks increased over the study period (14.1% in 2000 vs. 30.6% in 2007; p<.001), use in non-blacks remained higher (19.4% in 2000 vs 38.7% in 2007; p<.001). Total costs to Medicare per patient were more than $11,000 higher for black patients ($42,625 vs. $31,295; p<.001). Even after covariate adjustment, black race was independently associated with higher end-of-life costs (Cost Ratio 1.2, 95% CI (1.19,1.22); p<.001). Conclusion: Resource use at the end of life is higher among black Medicare patients with heart failure compared to non-black patients. Further research is needed to identify the factors that contribute to these observed differences.