Racial and Ethnic Differences in End-of-Life (EOL) Care and Planning: A Secondary Analysis of the Health and Retirement Study (HRS) 2004-2014
Abstract
Due to population ageing, coupled with advances in medical practices, more older Americans have a greater chance to consider end-of-life (EOL) care options such as hospice use and advance care planning, including the completion of two forms of advance directives, living wills and the Durable Power of Attorney for Health Care (DPAHC). Despite the documented benefits, advance care planning and hospice care are underutilized. A number of studies have been conducted to identify the factors affecting advance care planning and hospice care use, and among those factors, racial and ethnic disparities in EOL care and planning have been well-documented. However, the results of previous studies are not consistent with findings from recent other studies. These conflicting findings are, at least, due to variation in specific covariates in each study. An examination of EOL care and planning with a more comprehensive and theory driven consideration of potential covariates is limited. Therefore, based on two theoretical frameworks, the Andersen’s Behavioral Model of Health Service Use (BM) and the Critical Race Theory (CRT), and using the Health and Retirement Study (HRS), which is a nationally representative dataset that includes an oversample of African Americans and Hispanics, the present study explored whether or not there are racial and ethnic differences in the completion of advance directives, place of death, and the receipt of hospice care by older non-Hispanic white, non-Hispanic black, and Hispanic adults after controlling for a comprehensive list of covariates. The covariates which have been identified by two theoretical frameworks and documented in the literature included 12 variables divided into three categories; predisposing factors: age, gender, marital status, place of birth, religion, and educational attainment; enabling factor: income; and need factors: limitations in physical functioning, the presence of chronic diseases, depressive symptoms, cognitive function, and geriatric syndromes (incontinence and falls). In addition, the present study examined the potential mediating effect of education and income on racial and ethnic differences in the completion of advance directives, place of death, and the receipt of hospice care as well as the potential moderating effect of gender on racial and ethnic differences in the completion of advance directives, place of death, and the receipt of hospice care. A secondary data analysis of the Health Retirement Survey (HRS), a nationally representative longitudinal panel survey collected by using a multi-stage area probability sampling, was utilized. The study initially included 6,518 HRS participants who have died at the age of 65 or above between 2004 and 2014 and have a completed an exit interview by a proxy, but final sample size was 5,312 decedents after cases with missing values from dependent variables, covariates, mediators, and moderators were excluded. The final sample size for testing the relationship between race and ethnicity and hospice use was 992 decedents since it was only asked at one survey wave due to changes in item wording and response categories for measuring the variable of hospice care use. Hierarchical logistic regression analyses were used to determine the independent influence of race and ethnicity on EOL outcomes. The analyses showed that race and ethnicity significantly predicted completion of ADs, either living wills or DPAHC, even after controlling for covariates. As compared to non-Hispanic whites, non-Hispanic blacks and Hispanics were less likely to have DPAHC or living wills. Race and ethnicity significantly predicted non-hospital death, as well. As compared to non-Hispanic whites, non-Hispanic blacks and Hispanics were less likely to die at non-hospital settings. However, race and ethnicity had no significant effect on hospice use. For the mediation analyses, the method suggested by Karlson, Holm, and Breen (KHB) was used. The KHB test showed that the relationship between race and ethnicity and the completion of living wills and DPAHC was significantly partially mediated by education and income. In particular, the degree of mediation was much larger for education than income. The interaction between race and ethnicity and gender did not have significant effects on the completion of living wills, place of death, and hospice use. However, there were significant interaction effects between race and ethnicity and gender on the completion of DPAHC. In particular, for non-Hispanic whites, the odds of completing DPAHC for female participants were 1.41 times that of non-Hispanic white male participants. From the CRT as an interpretative tool for understanding the complex mechanism of racial and ethnic gaps in EOL care and planning, the findings can be evidence that the source of the gaps may be structural racism, which interacts with gender, socio-economic status such as income and educational attainment, religion, and other social identities to create racialization in health care outcomes. (Abstract shortened by ProQuest.)
Subject Area
Social work|Ethnic studies
Recommended Citation
Han, Junghee, "Racial and Ethnic Differences in End-of-Life (EOL) Care and Planning: A Secondary Analysis of the Health and Retirement Study (HRS) 2004-2014" (2019). ETD Collection for Fordham University. AAI13428145.
https://research.library.fordham.edu/dissertations/AAI13428145
