Racial differences in hospice revocation to pursue aggressive care.

BACKGROUND: Hospice provides supportive care to terminally ill patients at the end of life. However, some enrollees leave hospice before death in search of therapies that may prolong survival. Because of a greater preference for life-sustaining therapies at the end of life, African American patients may be more likely than white patients to withdraw from hospice to seek life-prolonging therapies. METHODS: In a secondary data analysis of African American and white patients discharged from VITAS hospice programs between January 1, 1999, and December 31, 2003, we used logistic regression to examine the association between race and discharge disposition defined as hospice revocation to pursue aggressive care (eg, emergency medical care, chemotherapy, or invasive medical intervention) vs all other discharges. We used a Cox proportional hazards model to examine survival at 1 year after hospice revocation in a subgroup of enrollees from Florida hospice programs. RESULTS: Of the 166 197 enrollees, 2.8% revoked hospice to pursue aggressive care, and African American patients were more likely than white patients to do so (4.5% vs 2.5%; P< .001). In multivariate analysis, African American patients had a 70% higher odds of leaving hospice to pursue life-prolonging therapies (odds ratio, 1.70; 95% confidence interval, 1.57-1.84). In the subgroup analysis, 48.4% of the enrollees who revoked hospice to pursue life-prolonging therapies were still alive at 1 year. CONCLUSIONS: African American patients were more likely than white patients to revoke hospice to pursue life-prolonging therapies. Models of health care that couple curative and palliative therapies may be more attractive to African American patients and more effective at maximizing continuity throughout life-limiting illness.

Comparison of botulinum neurotoxin preparations for the treatment of cervical dystonia.

BACKGROUND: Comparative studies of botulinum neurotoxin preparations to date have generally examined 2 preparations at prespecified dose ratios in relatively homogeneous groups of patients under controlled study conditions. It is unclear whether the differences in adverse-event rates that have been noted under these controlled conditions can be generalized to the broader population of cervical dystonia patients, who are treated with a wider range of doses in a variety of settings. OBJECTIVE: We conducted a systematic review and analysis of the published literature to compare rates of dysphagia and dry mouth in studies of botulinum neurotoxin products. METHODS: We searched the MEDLINE, EMBASE, Biosis, SciSearch, JICST (Japan Science and Technology Center), and Pascal databases from 1985 through 2006 using the terms cervical dystonia, spasmodic torticollis, and botulinum toxin for original English-language studies of Botox, Dysport, or Myobloc in the treatment of cervical dystonia (or spasmodic torticollis) that documented adverse events by treatment or patient. Studies that involved patients with various types of dystonias or movement disorders were included as long as adverse events were reported separately for those with cervical dystonia. Rates of dysphagia with the original preparation of Botox were considered separately from those with the current preparation of Botox. RESULTS: Seventy published articles were included in the analysis (30 Botox, 24 Dysport, 3 Botox + Dysport, 11 Myobloc, 2 Botox + Myobloc). Mean total doses per treatment ranged from 60 to 374 U for Botox, 125 to 1200 U for Dysport, and 579 to 19,853 U for Myobloc. Botox was associated with a significantly lower rate of dysphagia than Dysport, with mean dysphagia rates of 10.5% for original Botox, 8.9% for current Botox, and 26.8% for Dysport (both, P < 0.05). Myobloc was associated with dry mouth (3.2%-90.0%) in 9 of 13 studies, but this adverse event was not reported in a sufficient number of studies of botulinum toxin type A preparations (Botox, n = 2; Dysport, n = 6) to permit statistical comparison. In the weighted analysis, the duration of effect differed between botulinum neurotoxin products (current Botox > Myobloc > original Botox > Dysport; all, P < 0.001), but only 43 (61.4%) of the 70 studies reported duration, and the definitions varied. CONCLUSION: The results of this analysis indicate differences in adverse-event rates between botulinum neurotoxin preparations, suggesting that use of these products should be based on their individual dosing, efficacy, and safety profiles.

Racial differences in the growth of noncancer diagnoses among hospice enrollees.

Patients with noncancer life-limiting illnesses now represent over half of all hospice enrollees, compared to only one-quarter of enrollees in 1992. Whether this growth in enrollees with noncancer diagnoses has been similar for Caucasians and African Americans, a group historically underrepresented in hospice, has not been described. The purpose of this study was to compare rates of noncancer diagnoses among African American and Caucasian hospice enrollees. We analyzed data from the administrative database of VITAS Healthcare Corporation, including all African Americans and Caucasians discharged from hospice between January 1, 1999 and December 31, 2003. Of the 166,390 eligible discharges, 14.6% were African American, and 85.4% were Caucasian. Over the five-year study period, there was a similar increase in the crude proportion of enrollees with noncancer diagnoses in both groups, from 42% to 49.7% among African Americans and 57.9% to 64.3% among Caucasians. However, in multivariate analysis (adjusted for age, gender, admission level of care, payment source, Health Maintenance Organization (HMO) use, discharge year, and hospice program characteristics-size, location, presence of an inpatient unit), African Americans had 32% lower odds of having a noncancer (vs. cancer) diagnosis than Caucasians (odds ratio [OR] 0.68 [0.66, 0.77]). While numerous studies document lower rates of hospice use among African Americans than Caucasians, these findings suggest disease-specific differences in patterns of hospice use, with greater disparities in hospice use among African Americans with noncancer diagnoses than those with cancer diagnoses. Targeted efforts to increase hospice use among African Americans with noncancer diagnoses may be important in reducing racial disparities in overall hospice use and improving the quality of care for dying African Americans.

Ethnic differences in the place of death of elderly hospice enrollees.

Elderly minorities are more likely to die in inpatient settings than their Caucasian counterparts. It is not known whether this difference is due to cultural preferences for place of death or decreased access to hospice. This analysis examines ethnic differences in the place of death of elderly hospice patients. Using data from a large, national hospice provider, elderly (> or = 65) African-American, Hispanic, and Caucasian decedents admitted to hospice between January 1, 2000, and December 31, 2003, were identified. Of the 115,854 eligible decedents, 78.3% were Caucasian, 10.7% African American, and 11% Hispanic. Hispanics and African Americans were more likely to die in inpatient hospice settings than Caucasians (38.5%, 38.5%, and 32%, respectively). After adjustment for demographic and hospice use variables, older African Americans had higher odds than older Caucasians of dying in an inpatient hospice setting than a nursing home (odds ratio (OR)=1.12, 95% confidence interval (CI)=1.07-1.19). However, African-American ethnicity was not a significant predictor of death in an inpatient setting versus home (OR=1.03, 95% CI=0.97-1.08)). Hispanics had lower odds than Caucasians of death in an inpatient hospice setting than at home (OR=0.88, 95% CI=0.84, 0.93) and higher odds of death in an inpatient setting than a nursing home (OR=1.45, 95% CI=1.37-1.53). Admission to hospice reduces but does not eliminate ethnic differences in place of death. Further research should examine the effect of individual and cultural preferences for place of death on decisions to enroll in hospice.