Advance Care Planning and Treatment Intensity Before Death Among Black, Hispanic, and White Patients Hospitalized with COVID-19.

BACKGROUND: Black and Hispanic people are more likely to contract COVID-19, require hospitalization, and die than White people due to differences in exposures, comorbidity risk, and healthcare access. OBJECTIVE: To examine the association of race and ethnicity with treatment decisions and intensity for patients hospitalized for COVID-19. DESIGN: Retrospective cohort analysis of manually abstracted electronic medical records. PATIENTS: 7,997 patients (62% non-Hispanic White, 16% non-Black Hispanic, and 23% Black) hospitalized for COVID-19 at 135 community hospitals between March and June 2020 MAIN MEASURES: Advance care planning (ACP), do not resuscitate (DNR) orders, intensive care unit (ICU) admission, mechanical ventilation (MV), and in-hospital mortality. Among decedents, we classified the mode of death based on treatment intensity and code status as treatment limitation (no MV/DNR), treatment withdrawal (MV/DNR), maximal life support (MV/no DNR), or other (no MV/no DNR). KEY RESULTS: Adjusted in-hospital mortality was similar between White (8%) and Black patients (9%, OR=1.1, 95% CI=0.9-1.4, p=0.254), and lower among Hispanic patients (6%, OR=0.7, 95% CI=0.6-1.0, p=0.032). Black and Hispanic patients were significantly more likely to be treated in the ICU (White 23%, Hispanic 27%, Black 28%) and to receive mechanical ventilation (White 12%, Hispanic 17%, Black 16%). The groups had similar rates of ACP (White 12%, Hispanic 12%, Black 11%), but Black and Hispanic patients were less likely to have a DNR order (White 13%, Hispanic 8%, Black 7%). Among decedents, there were significant differences in mode of death by race/ethnicity (treatment limitation: White 39%, Hispanic 17% (p=0.001), Black 18% (p<0.0001); treatment withdrawal: White 26%, Hispanic 43% (p=0.002), Black 28% (p=0.542); and maximal life support: White 21%, Hispanic 26% (p=0.308), Black 36% (p<0.0001)). CONCLUSIONS: Hospitalized Black and Hispanic COVID-19 patients received greater treatment intensity than White patients. This may have simultaneously mitigated disparities in in-hospital mortality while increasing burdensome treatment near death.

Treatment intensity and mortality among COVID-19 patients with dementia: A retrospective observational study.

BACKGROUND: We sought to determine whether dementia is associated with treatment intensity and mortality in patients hospitalized with COVID-19. METHODS: This study includes review of the medical records for patients >60 years of age (n = 5394) hospitalized with COVID-19 from 132 community hospitals between March and June 2020. We examined the relationships between dementia and treatment intensity (including intensive care unit [ICU] admission and mechanical ventilation [MV] and care processes that may influence them, including advance care planning [ACP] billing and do-not-resuscitate [DNR] orders) and in-hospital mortality adjusting for age, sex, race/ethnicity, comorbidity, month of hospitalization, and clustering within hospital. We further explored the effect of ACP conversations on the relationship between dementia and outcomes, both at the individual patient level (effect of having ACP) and at the hospital level (effect of being treated at a hospital with low: <10%, medium 10%-20%, or high >20% ACP rates). RESULTS: Ten percent (n = 522) of the patients had documented dementia. Dementia patients were older (>80 years: 60% vs. 27%, p < 0.0001), had a lower burden of comorbidity (3+ comorbidities: 31% vs. 38%, p = 0.003), were more likely to have ACP (28% vs. 17%, p < 0.0001) and a DNR order (52% vs. 22%, p < 0.0001), had similar rates of ICU admission (26% vs. 28%, p = 0.258), were less likely to receive MV (11% vs. 16%, p = 0.001), and more likely to die (22% vs. 14%, p < 0.0001). Differential treatment intensity among patients with dementia was concentrated in hospitals with low, dementia-biased ACP billing practices (risk-adjusted ICU use: 21% vs. 30%, odds ratio [OR] = 0.6, p = 0.016; risk-adjusted MV use: 6% vs. 16%, OR = 0.3, p < 0.001). CONCLUSIONS: Dementia was associated with lower treatment intensity and higher mortality in patients hospitalized with COVID-19. Differential treatment intensity was concentrated in low ACP billing hospitals suggesting an interplay between provider bias and "preference-sensitive" care for COVID-19.