1. Racial Disparities in Primary Care and Utilization of Health Services at the End-of-Life Andrea Kronman, MD Boston University School of Medicine

2. Background  End-of-life care 6 % of Medicare beneficiaries die each year Decedents use 30 % of Medicare revenues Under-treatment of symptoms, especially pain Over-treatment with ineffective / unwanted procedures  Role of primary care at end of life ? More likely to elicit patients’ wishes ?  Racial differences Minorities less likely to have advance directives Minorities more likely to die in hospital

3. Minority Status Hospital Days at End Of Life Less hospice Less advance directives Different patient preferences Different primary care use

4. Study Objective Race / Ethnicity Differences Hospital Days End Of Life Primary Care Examine role of primary care in racial differences of hospital days at the end of life

5. Utilization Variables Primary Care Variables Covariates Death 6 months12 months Study Sample 140,000 Medicare decedents July - December 2001 National, stratified random sample of 1 million beneficiaries Minorities over-sampled: Black, Hispanic > 66 years old, continuous Medicare A & B, no ESRD Methods Study Design Retrospective database analysis of Medicare decedents during their last 18 months of life

6. hospital daysprimary care death 6 months12 months Primary Care (Independent Variables) Number of primary care visits Ambulatory Care Sensitive Conditions (ACSC) admissions Utilization (Dependent Variable) Total hospital days Measures covariates

7. hospital daysprimary care death 6 months12 months Analysis Covariates demographics (age, gender, Medicaid as income proxy) nursing home use comorbidity ( DxCG prospective risk adjustment score) geographic location (county) covariates Chi-Square and ANOVA Multivariate Linear Regression

8. Decedent Characteristics Health Care Utilization

9. Primary Care Visits Predict Fewer Total Hospital Days At End of Life * * Adjusted for all covariates

10. Admission for ACSC Predicts More Hospital Days At End of Life * * Adjusted for all covariates

11. Racial Differences Visits to Primary Care Physician p <.01

12. Racial Differences Admission Rates * for Chronic ACSC * # of admissions for this diagnosis / 100 people with the diagnosis p <.01

13. Model 1: Adjusts for demographics and illness burden Model 2: Model 1 + county Racial Differences Total Hospital Days at End-of-Life

14. Model 2: Adjusts for all covariates Model 3: Model 3 + primary care variables * All p <.01 Hospital Days * Primary Care Mediates Racial Differences in Hospital Days

15. Conclusions Primary Care Preceding the End of Life:  Blacks and Hispanics  fewer primary care physician visits  less access to quality primary care End-Of-Life Utilization:  Blacks and Hispanics used more hospital days  partially explained by differences in preceding primary care use

16. Implications Increasing primary care at the end of life could:  Decrease expenditures by decreasing costly hospital days  Improve quality of care, particularly for Blacks and Hispanics

17. Acknowledgements  Arlene Ash, PhD  Karen Freund, MD, MPH  Jim Burgess, PhD  Jenn Fonda, MA