Health Disparities in Hospice in Nursing Homes

在美国，超过15,600家养老院(NHS)为130多万老年人提供长期护理 成年人，其中约20%是种族和少数民族。大约40%的NH居民已经进入 疾病，在大流行之前，65岁或以上的所有死亡人数中有27%以上发生在 NHS，这使得高质量的临终关怀至关重要。先前的研究发现种族和民族差异 在NH EOL护理中心。临终关怀是一项政府福利，允许由专家提供临终关怀 跨学科团队。及时登记临终关怀是一种最佳做法，建议有以下情况的NH居民 晚期疾病。然而，在NHS死亡的人中，只有三分之一的人登记在临终关怀处，30%的登记居民 接受不到一周的临终关怀。对国民健康保险制度中与隐性偏见、系统性偏见有关的差异的担忧 种族主义和结构性种族主义随着流行病的流行而增加。2020年间，种族和少数民族NH 居民受到新冠肺炎的影响不成比例，死亡率上升了32%，但临终关怀的使用率下降了 在大多数州。在NH临终关怀登记中，关于种族和民族差异的知识存在差距， 提供的临终关怀质量，以及相关的EOL结果。大流行如何影响临终关怀的使用，如果 任何相关的变化是否持久也是未知的。为了解决这些差距，我们提出了一种顺序 以多纳贝迪安的结构、过程和结果质量为指导的解释性混合方法研究 该框架和NIMHD少数民族健康和健康差距框架。我们的目标是：1)确定 随着时间的推移，临终关怀登记的种族和民族差异以及提供的临终关怀的质量，因素 影响这些差异的因素，以及新冠肺炎如何改变这些差异；2)识别种族和民族 NH终生结局随时间的差异，影响这些差异的因素，包括临终关怀 注册人数和临终关怀的质量，以及新冠肺炎如何改变这些差异；以及3)描述 被认为是促进临终关怀使用和提高种族和地区临终关怀质量的障碍 少数民族NH居民。为了实现目标1和目标2，我们将使用行政数据和公开数据 从2015年到2024年，包括最低数据集以及医疗保险临终关怀和住院索赔(n≈800万) 死亡的NH居民和该样本中登记到临终关怀中心的子集(n≈200万)。我们将包括 所有可用的种族和民族类别以及临终关怀登记、临终关怀质量的综合衡量标准 护理和EOL结果。为了达到目标3，我们将有目的地抽样16个不同地点的NHS，分别是 临终关怀服务的使用率或高或低，≥有30%的居民是少数族裔。我们将进行 对一名管理人、临终关怀规划者和两名种族/民族的家庭照顾者进行半结构化访谈 每个NH的少数死者(即，一个使用临终关怀和一个不使用临终关怀)。这项研究的结果 将为国家、州和NH级别的循证政策提供信息，并影响基于实践的倡议 这可以促进在NHS生活和死亡的不同美国人公平地获得高质量的临终关怀。

In the US, more than 15,600 nursing homes (NHs) provide long-term care to more than 1.3 million elderly adults, of whom about 20% are racial and ethnic minorities. About 40% of NH residents have advanced illness, and prior to the pandemic more than 27% of all deaths in those ages 65 years or older occurred in NHs, making high-quality end-of-life (EOL) care critical. Prior research has found racial and ethnic disparities in NH EOL care. Hospice, a government benefit, allows for EOL care to be provided by a specialist interdisciplinary team. Timely hospice enrollment is a best practice and is recommended for NH residents with advanced illness. However, of those dying in NHs only 1/3 enroll in hospice, and 30% of the enrolled residents receive hospice care for less than a week. Concerns about disparities in NHs related to implicit bias, systemic racism, and structural racism increased with the pandemic. During 2020, racial and ethnic minority NH residents were disproportionately affected by COVID-19 as mortality rose by 32%, yet hospice use decreased in most states. There are gaps in knowledge about racial and ethnic disparities in NH hospice enrollment, the quality of hospice care provided, and related EOL outcomes. How the pandemic impacted hospice use and if any related changes were long lasting is also unknown. To address these gaps, we propose a sequential explanatory mixed methods study guided by Donabedian's Structure, Process, and Outcomes Quality Framework and the NIMHD Minority Health and Health Disparities Framework. Our aims are to: 1) Identify racial and ethnic differences in hospice enrollment and the quality of hospice care provided over time, factors that influence these differences, and how COVID-19 changed these differences; 2) Identify racial and ethnic differences in NH EOL outcomes over time, factors that influence these differences including hospice enrollment and the quality of hospice care, and how COVID-19 changed these differences; and 3) Describe perceived facilitators and barriers that contribute to hospice use and quality of hospice care in racial and ethnic minority NH residents. To achieve Aims 1 and 2, we will use administrative and publicly available data from 2015 to 2024, including the Minimum Data Set and Medicare hospice and inpatient claims (n ≈ 8 million) of NH residents who died and a subset of this sample who enrolled in hospice (n ≈ 2 million). We will include all available racial and ethnic categories and comprehensive measures of hospice enrollment, hospice quality of care, and EOL outcomes. To meet Aim 3, we will purposively sample 16 NHs that vary in location, are either high or low users of hospice, and ≥ 30% of residents are racial or ethnic minorities. We will conduct semi-structured interviews with an administrator, hospice care planner, and 2 family caregivers of racial/ethnic minority decedents (i.e., one that used hospice and one that did not) from each NH. Results from this study will inform evidence-based policies at the national, state, and NH level and influence practice-based initiatives that can promote equitable access to high-quality hospice for diverse Americans living and dying in NHs.