Health Disparities in Hospice in Nursing Homes

在美国，超过15，600家养老院（NH）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居民已经提前 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，使高质量的生命末期（EOL）护理至关重要。先前的研究发现， 在NH-EOL护理中。临终关怀是一项政府福利，允许由专家提供临终关怀 跨学科团队及时的临终关怀登记是一种最佳做法，建议NH居民 晚期疾病然而，在NHS死亡的人中，只有1/3的人参加了临终关怀， 接受不到一周的临终关怀对与内隐偏见、系统性 种族主义和结构性种族主义随着这一流行病而增加。在2020年，种族和少数民族NH 居民受到COVID-19的不成比例的影响，死亡率上升了32%，但临终关怀的使用却减少了 在大多数州。在NH临终关怀登记中，对种族和民族差异的认识存在差距， 提供的临终关怀质量和相关的EOL结局。大流行如何影响临终关怀的使用， 任何相关的变化是否持续很长时间也是未知的。为了解决这些差距，我们提出了一个连续的 Donabedian的结构、过程和结果质量指导下的解释性混合方法研究 国家少数民族健康和健康差距框架。我们的目标是：1）识别 随着时间的推移，临终关怀登记和临终关怀质量的种族和民族差异， 影响这些差异的因素，以及COVID-19如何改变这些差异; 2）确定种族和民族 NH EOL结局随时间的差异，影响这些差异的因素包括临终关怀 招募和临终关怀的质量，以及COVID-19如何改变这些差异;以及3）描述 在种族和民族中， 少数民族居民。为了实现目标1和2，我们将使用行政和公开数据 从2015年到2024年，包括最低数据集和医疗保险临终关怀和住院索赔（1000万） 死亡的NH居民和参加临终关怀的该样本的一个子集（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 和EOL结果。为了满足目标3，我们将有目的地抽样16个位置不同的NH， 临终关怀的高或低用户，≥ 30%的居民是少数民族或种族。我们会进行 半结构化访谈管理员，临终关怀规划师，和2个家庭照顾者的种族/民族 少数死者（即，一个使用临终关怀，一个没有）从每个NH。本研究结果 将为国家、州和NH层面的循证政策提供信息，并影响基于实践的举措 这可以促进平等获得高质量的临终关怀为不同的美国人生活和死亡的国家卫生服务。

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.