Race and Medicine

Race and Medicine

August 12, 2019
2 min read

Racial disparities exist in use of palliative care for patients with ESKD

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Lili Chan

While the use of palliative care increased for all hospitalized patients with ESKD, black and Hispanic patients were significantly less likely to receive palliative care referrals and services than white patients, according to a recently published study.

“Patients with end-stage kidney disease on dialysis have high mortality rates,” Lili Chan, MD, and Girish N. Nadkarni, MD, both of the department of medicine at Mount Sinai Hospital in New York, told Healio/Nephrology. “Palliative care services have been shown to decrease the burden of debilitating symptoms, facilitate advanced care planning, and reduce hospital admissions and in-hospital death. We found that while the overall proportion of patients admitted to the hospital receiving palliative care services has increased, rates remain low. Only 2.7% of patients received palliative care in 2014.”

To assess potential racial disparities in palliative care services, researchers used data from the National Inpatient Sample to conduct a retrospective cohort study of 5,230,865 patients on dialysis who were hospitalized from 2006 to 2014.

Girish N. Nadkarni

The primary outcome of the study was the temporal trend of palliative care referral overall and by race/ethnicity. Also considered were racial disparities in palliative care utilization in hospitals based on different hospital types (eg, proportion of minority patients, size, region, location and teaching status) and patient-level factors (eg, Charlson comorbidity index score, do-not-resuscitate status, comorbidities, insurance, median income, age and gender).

Researchers found that, while the rate of referral for palliative care increased from 0.24% in 2006 to 2.70% in 2014 for all patients, white patients had the fastest increase (0.41% per year vs. 0.21% per year and 0.22% per year for black and Hispanic patients, respectively).

Animated hands of different races linked 
While the use of palliative care increased for all hospitalized patients with ESKD, black and Hispanic patients were significantly less likely to receive palliative care referrals and services than white patients.
Source: Adobe Stock

Due to these disproportionate increases in the rates of palliative care utilization, black and Hispanic patients were significantly less likely than white patients to receive palliative care services (adjusted OR = 0.72 to 0.84 for black patients and aOR = 0.46 for Hispanic patients). In addition, researchers observed that patients with private insurance were more likely to receive palliative care services than those with Medicare and that hospitals with more minorities were less likely to provide palliative care. Finally, researchers noted that palliative care referral was similar between Asian and white patients and may be associated with the fact that Asian patients tend to have a higher socioeconomic status compared with other minorities.

“Our research highlights the low rates of palliative care use in patients with ESKD and adds to the growing literature of racial and ethnic disparities in the care of patients with kidney disease,” Chan and Nadkarni, said. “We hope to encourage discussion and motivate providers caring for patients with ESKD to offer palliative care to all patients regardless of race and ethnicity. Further research into how provider race, ethnicity, and diversity training impacts the care of patients with kidney disease is needed.”

In a related editorial, Vanessa Grubbs, MD, of the University of California, San Francisco, wrote: “The medical literature is rife with studies showing how minority groups fare worse than their white counterparts in arguably every outcome and from cradle to grave … The authors were surprised to find that black and Hispanic patients received less palliative care even in high- and medium-minority hospitals compared with white ones, ‘where presumably providers were exposed to a higher volume of minority patients.’ Not only does this finding underscore the importance of a diverse provider workforce, but also that nonminority providers must do more than simply exist with large minority populations if disparities are to be resolved.” – by Melissa J. Webb

Disclosures: Wen reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial