Disparities in Hospital Utilization at the End of Life: Influence of Age, Race, Insurance Type, and Hospital Capacity

Purpose: This study examines hospital utilization at the end of life for older adults and the influence of patient characteristics in comparison to health system characteristics. Design and Methods: Within Maricopa County, Arizona, hospital utilization data were obtained for all non-traumatic, inpatient deaths (n=3,409) for 2006. Age, gender, race/ethnicity, health insurance, clinical severity, and hospital bed capacity were explored in relationship to hospital utilization (i.e., duration of hospital admission), intensive care utilization, and mechanical ventilation. Results: Multivariate regression analysis indicates that, controlling for hospital bed capacity and clinical severity, race/ethnicity was not significant, while advanced patient age (p< .05) and lack of health plan (p< .001) were significantly related to shorter duration of the terminal hospitalization. Logistic regression analysis further identified that race/ethnicity was significantly related to increased odds of intensive care utilization and mechanical ventilation for minorities in comparison to whites (for Hispanics, p< .005; Native Americans, p<.05). Greater hospital bed capacity had a significant, positive relationship to increased hospital duration, intensive care utilization, and mechanical ventilation. Implications: The results regarding advanced age and reduced level of hospital utilization indicate potentially different approaches to treatment intensity for the oldest old. In addition, while race/ethnicity was not correlated with duration of hospitalization, it did play a significant role for specific levels of care such as intensive care and mechanical ventilation. Finally, the modifying effect of lack of health insurance and hospital bed capacity indicate that disparities in care may be highly sensitive to health system and payor characteristics.