Practice Matters-Palliative Care
What Accounts for Disparities in the Use of Palliative Stroke Care? It May Not Be What You Think
By Mark Moran
December 7, 2017
ARTICLE IN BRIEF
Hospital systems — and not necessarily only the primary ethnic population of those hospitals — may contribute to disparities involving palliative care for patients after ischemic stroke and intracerebral hemorrhage.
Why do black and other ethnic minorities receive less palliative care after ischemic stroke and intracerebral hemorrhage (ICH)? Past studies have suggested that the attitudes of the patients themselves — their religious beliefs and lack of knowledge or trust in palliative care solutions — drive their preferences for lifesaving options in critical care scenarios.
But a new analysis in the October 14 online edition of Critical Care Medicine suggests that it might be the systems in place in hospitals serving minority populations — and not the belief systems of individual patients — that account for these racial disparities in care.
Analysis of data from the Nationwide Inpatient Sample confirmed that ethnic minorities who had a stroke were less likely to receive palliative care than whites. But it also showed that all patients with stroke—regardless of racial/ethnic identity—were less likely to receive palliative care if they were cared for in largely minority-serving hospitals.
“What is new about our study is that the racial make-up of a given hospital determines in part the use of palliative care after stroke regardless of race,” lead author Roland Faigle, MD, PhD, assistant professor of neurology at Johns Hopkins Medicine told Neurology Today. “When we examined the use of palliative care services in majority-white, racially integrated, and predominantly minority hospitals, both ethnic minority and white stroke patients alike were less likely to receive palliative care as the proportion of minority patients treated at a given hospital stratum increases.”
“Individual factors on the provider or the patient side are only one small part of the story in understanding health care disparities in services,” Dr. Faigle said. “Understanding system level determinants of race disparities is critically important to develop effective mitigation strategies aimed at eliminating disparities in stroke care.”
For clinicians treating patients with stroke, Dr. Faigle said the most important message from the analysis is the need to be aware of any given patient's potential need for palliative care and to inquire whether resources to address such need are available and being used. “In addition, physicians should have conversations with patients and their families about their understanding of the patient's prognosis and expressed wishes for aggressiveness of care, or lack thereof, at any time during the course of the hospitalization,” Dr. Faigle said.
STUDY DESIGN, FINDINGS
For the analysis, data were obtained from the Nationwide Inpatient Sample, a part of the Healthcare Cost and Utilization Project, sponsored by the Agency for Healthcare Research and Quality. ICH and adult ischemic stroke cases were identified using ICD-9-CM codes.
Among stroke admissions, Dr. Faigle and colleagues compared differences in palliative care use among, and by the patient's ethnicity, within hospitals serving predominantly white or predominantly ethnic minority patients.
Hospitals were stratified into three groups based on the proportion of minority patients: hospitals serving predominantly white stroke patients (< 25 percent minority patients; “white hospitals”); hospitals serving both minority and white stroke patients (25-50 percent minority patients, “mixed hospitals”); and hospitals serving predominantly minority stroke patients (> 50 percent minority patients; “minority hospitals”).
Dr. Faigle and colleagues found that among hospitals included for the ICH analysis, the median rate of palliative care use in predominantly white hospitals was 8.5 per 100 ICH admissions, whereas in mixed and minority hospitals, the median palliative care use rates were 6.3 and 2.5 per 100 ICH admissions, respectively. Among hospitals included for analysis of ischemic stroke, the median palliative care use rate in predominantly white hospitals was 2.2 per 100 ischemic stroke admissions, whereas the median rates of palliative care use in mixed and minority hospitals were 1.5 and 0.5 per 100 admissions. The researchers arrived at these findings after controlling for disease severity, demographics, comorbidities, socioeconomic surrogates, and other hospital characteristics.
Health services researchers who reviewed the report for Neurology Today said the findings are not surprising. “When you look at racial and ethnic disparities relating to access to specialty care, generally they seem to be pronounced among African-Americans and Latinos,” John Ney, MD, MPH, assistant professor of neurology at Boston University and staff neurologist at the VA Medical Center in Bedford, MA, said. “It's to be expected that palliative care as a specialty would follow that trend.”
The study shows disparities on two levels, Dr. Ney said. “One is at the intra-hospital level where minority patients in pretty much any setting utilize palliative care services substantially less. The other is at the inter-hospital level where predominantly minority hospitals utilize substantially less palliative care for stroke patients even when patients are not minorities.”
“System variables could include whether the hospital has algorithms in place to alert physicians to patients who could benefit from palliative care services and staffing that would allow access to a palliative care specialist,” Dr. Ney added.
Salvador Cruz-Flores, MD, MPH, chair of neurology at Texas Tech University Health Science Center in El Paso, emphasized that the study does not discount the influence of individual patient characteristics; rather, he said, it points out that they are not the only variables in racial disparities. “Primarily ‘minority’ hospitals in this study could have limitations that can include but are not limited to the availability of the palliative care service, the presence of social work, and a culture within the system about involving palliative care, among others,” he said in comments to Neurology Today.
Dr. Cruz-Flores added: “Disparities in access to care involve a wider set of issues that include social, economic, and educational factors that impact the ability of a person in a minority group to have access to care. Over the last few years there has been an increasing understanding of their presence. However, I think that there have not been systematic efforts on finding solutions.”
Dr. Faigle noted that there may be a subtle interplay between individual patient characteristics and systemic variables affecting palliative care for stroke patients.
“If the majority of patients in a hospital has a certain preference/belief, the resultant treatment is more likely to be applied to all patients in that hospital,” he said. “If the majority of patients in a hospital is an ethnic minority, then everyone, even those who are white, will receive treatment similar to that of the majority patient population, since the local practices have been primed as such.”
Dr. Ney echoed those remarks. “Palliative care is a fairly new specialty and there needs to be education of patients and families that palliative care does not simply mean, ‘We aren't taking care of you anymore’—a perception that minority populations may be especially sensitive to.”
What can be done to reverse disparities in care? Dr. Ney stressed that strategies should include education, increasing the number of palliative care providers at hospitals, and hospital system reforms that incorporate palliative care into the work flow in care of stroke.
Meanwhile, Dr. Faigle said, clinicians treating the individual patient should focus on what each individual patient thinks and wants in an unbiased manner, free of the physician's own beliefs and attitudes. “In the reality of an often-fluid health status during the course of a stroke hospitalization, ongoing communication regarding goals of care is key to ensuring that the care delivered is congruent with the wishes of the patients and their families.”
EXPERTS: ON DISPARITIES IN PALLIATIVE CARE AFTER STROKE AND ICH