Why does dying cost more for people of color? New study takes a deeper look
By a
And despite years of searching for the reason, no one has quite figured out why.
A new study by a
Unlike other kinds of health cost disparities, they didn't find that the difference could be explained by differences in patients' income, education, medical conditions or other individual factors such as use of hospice. The differences also persisted after they took into account general health spending patterns in a dying person's area.
The team also took into account specific factors related to the unique circumstances that are present at the end of life - the first time this has been done. These indicators of patients' own preferences still didn't explain the differences in cost.
As a result, the researchers conclude that something bigger, rooted in the healthcare system as a whole, must be going on. After all the other factors were figured in, the cost of that last six months of life was
"We need to look harder for the causes of disparities in end-of-life care costs, and look at factors on the provider level and health system level, including family dynamics that may come into play," says Elena Byhoff, M.D.,
Byhoff and her colleagues, including U-M end-of-life care researchers
New
Previous work by Langa and others has shown that end-of-life care costs tend to be lower for patients who have spelled out their wishes to limit treatment ahead of time.
Patient preferences have been seen by many as a key factor in end-of-life cost disparities, but are hard to study. The U-M team found a way to take them into account in their analysis by using data from the Health and Retirement Study, based at the
They gathered data from interviews with more than 7,100 seniors over age 65 with traditional
They also used HRS interviews with the seniors' survivors, which allowed them to find out if the death had been expected, if the patient had discussed their end-of-life treatment preferences with their survivor, and if they had a formal advance directive in place when they died.
Then, the researchers matched each senior's survey data with his or her
The researchers used an End-of-Life Expenditure Index developed by the
In all, 78 percent of the people studied were non-Hispanic whites, 14.5 percent were non-Hispanic blacks, 4.7 percent were Hispanic and 2.8 percent were members of other racial or ethnic groups.
At first glance, without correcting for any differences between groups, the
Those differences in cost were cut in half after the researchers took into account a wide range of demographic, socioeconomic, geographic and health status differences among the people in each racial and ethnic group. But still, the final months of a black person's life cost the
That left 'patient preferences' as the last factor to take into account. The researchers bundled together the presence of an advance directive, discussion of end-of-life treatment preferences, and the fact that a death was expected, to reflect ways in which patients could express their preferences. They did not have access to the advance directives themselves.
But even after factoring these in, the disparities persisted. The
The persistence of disparities even after taking into account so many factors makes end-of-life care different from other types of care, where factors such as income, education and ZIP code explain much of the difference in outcomes and spending between racial and ethnic groups.
Finding out what factors make the most difference in the last months of life will mean more research. But in the meantime, the researchers hope their findings will help encourage more patients, providers and families of all racial and ethnic backgrounds to start the conversation before it's too late, and uphold the wishes of the dying when they're known.
Keywords for this news article include: Health Policy,
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