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Racial Differences in Palliative Care Use After Stroke in Majority-White, Minority-Serving, and Racially Integrated U.S. Hospitals

Faigle, Roland MD, PhD1; Ziai, Wendy C. MD, MPH2; Urrutia, Victor C. MD1; Cooper, Lisa A. MD, MPH3; Gottesman, Rebecca F. MD, PhD1

doi: 10.1097/CCM.0000000000002762
Clinical Investigations

Objectives: Racial/ethnic differences in palliative care resource use after stroke have been recognized, but it is unclear whether patient or hospital characteristics drive this disparity. We sought to determine whether palliative care use after intracerebral hemorrhage and ischemic stroke differs between hospitals serving varying proportions of minority patients.

Design: Population-based cross-sectional study.

Setting: Inpatient hospital admissions from the Nationwide Inpatient Sample between 2007 and 2011.

Patients: A total of 46,735 intracerebral hemorrhage and 331,521 ischemic stroke cases.

Interventions: Palliative care use.

Measurements and Main Results: Intracerebral hemorrhage and ischemic stroke admissions were identified from the Nationwide Inpatient Sample between 2007 and 2011. Hospitals were categorized based on the percentage of ethnic minority stroke patients (< 25% minorities [“white hospitals”], 25–50% minorities [“mixed hospitals”], or > 50% minorities [“minority hospitals”]). Logistic regression was used to evaluate the association between race/ethnicity and palliative care use within and between the different hospital strata. Stroke patients receiving care in minority hospitals had lower odds of palliative care compared with those treated in white hospitals, regardless of individual patient race/ethnicity (adjusted odds ratio, 0.65; 95% CI, 0.50–0.84 for intracerebral hemorrhage and odds ratio, 0.62; 95% CI, 0.50–0.77 for ischemic stroke). Ethnic minorities had a lower likelihood of receiving palliative care compared with whites in any hospital stratum, but the odds of palliative care for both white and minority intracerebral hemorrhage patients was lower in minority compared with white hospitals (odds ratio, 0.66; 95% CI, 0.50–0.87 for white and odds ratio, 0.64; 95% CI, 0.46–0.88 for minority patients). Similar results were observed in ischemic stroke.

Conclusions: The odds of receiving palliative care for both white and minority stroke patients is lower in minority compared with white hospitals, suggesting system-level factors as a major contributor to explain race disparities in palliative care use after stroke.

1Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD.

2Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD.

3Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

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Dr. Faigle is supported by a Career Development Award (K23 NS101124) from the National Institute of Neurological Disorders and Stroke. Dr. Ziai received funding from a National Institutes of Health grant (1U01NS08082) for Minimally Invasive Surgery Plus r-tPA for Intracerebral Hemorrhage Evacuation III, from Headsense, Inc., and from grant number 5U01NS062851 for Clot Lysis Evaluation of Accelerated Resolution of Intraventricular Hemorrhage III. Dr. Urrutia’s institution received funding from Genentech for an investigator sponsored trial. Dr. Cooper is supported by grant K24HL083113 from the National Heart, Lung, and Blood Institute. Dr Gottesman is supported by K24AG052573 from the National Institute on Aging and is an Associate Editor for Neurology.

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