End-of-Life Hospitalization for African American and Non-Latino White Nursing Home Residents: Variation by Race and a Facility's Racial Composition

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Abstract
Background: Hospitalization of nursing home residents at the end of life is common, more so among African Americans. Whether a nursing home's racial mix is associated with hospitalization is unknown. Objective: This study examined the association between race, a nursing home's racial mix, and end-of-life hospitalization. Design: This was a retrospective cohort study. Setting/Subjects. Studied were nursing home residents in New York (n = 14,159) and Mississippi (n = 1481) who died in 1995–1996 and had a minimum data set (MDS) assessment within 120 days of death. Measurements: The outcome measure was the odds of hospitalization in the last 90 days of life. A variable reflecting a nursing home's proportion of African American residents (in 1995–1996) represented a nursing home's racial mix. Results: Forty-six percent of African Americans and 32% of whites were hospitalized in the last 90 days of life. After controlling for demographics, diagnoses, function, patient preferences (do-not-resuscitate [DNR]), and facility resources, nursing home residents in facilities having higher proportions of African American residents had greater odds of hospitalization (adjusted odds ratio [AOR] 1.14; 95% confidence interval [CI] 1.10, 1.18 in New York and AOR 1.35; 95% CI 1.24, 1.46 in Mississippi). Age and frailty interacted with race; older African Americans had a 16% greater likelihood (95% CI 1.08, 1.24) of hospitalization, and African Americans with more functional limitations had a 37% (95% CI 1.24, 1.51) greater likelihood of hospitalization than did comparable whites. Conclusions: It appears higher end-of-life hospitalization rates for African American residents are attributable to the facilities where most reside, and to differential hospitalization of older or more functional limited residents.