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Mularski RA, Lorenz KA, Asch SM, Ettner SL, Yano EM, Santiago SM. Racial disparity in site of death: African-Americans and Hispanics at higher risk for hospital death. Paper presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA.
Objectives:Americans prefer to die at home, yet most deaths occur in hospitals. Because site of death has been suggested as a benchmark of palliative care performance, we sought to explore racial differences in site of death among veterans.Methods:Using the veterans Beneficiary Identification and Records Locator System and California death certificates in a retrospective cohort study, we identified all 8813 veteran deaths in California in fiscal year 2000 and linked data from the National Patient Care Database for a period of time extending to 2 years before death. We examined the association of race/ethnicity (Caucasian, African-American, Hispanic, other) with site of death (hospital, home, and long-term care facility) using a multinomial logit model, controlling for patient-level factors, such as disease and other demographics, and using fixed effects to account for variation among service areas. Race data was missing in 0.5% and imputation was performed with best subset method. We used bootstrapping to determine standard errors.Results:Statewide veteran deaths were among Caucasian 77%, African-American 13%, Hispanic 7%, and other 3%; 25% died at home, 52% in hospital, and 23% in long-term care. Compared to Caucasians, African Americans had a lower likelihood of home death (27% lower relative risk, 95% confidence interval 16% to 37%) but increased likelihood of hospital deaths (8% higher RR, 95% CI 1% to 15%). Hispanics had even stronger effects with a 19% (95% CI 10% to 29%) higher relative risk of hospital death compared to Caucasians. Advancing age, female gender, and diagnoses of dementia, cancer, or HIV increased risk for long-term care facility site of death compared to hospital; cancer diagnosis also increased chances of home death.Implications:African-American and Hispanic veterans were at relatively higher risk for hospital death. Subsequent work should explore these racial variations including possible factors that may mitigate this association, such as patient preferences, socioeconomic status, and access to treatment options.Impacts:We identified racial disparity in site of death among California veterans. Efforts to improve end-of-life and palliative care must be responsive to the growing number of racially and ethnically diverse veterans.