Kidney Replacement Therapy Use at End-of-Life Among Critically Ill Chinese and Non-Hispanic White Americans: A Single-Center Study
Year: 2024
Type: article
Study design: Observational Study
Abstract: Asian Americans represent the fastest growing racial group in the United States.1Asian Americans are the fastest-growing racial or ethnic group in the U.S.” Pew Research Center, Washington, D.C. (April 9 2021) https://www.pewresearch.org/short-reads/2021/04/09/asian-americans-are-the-fastest-growing-racial-or-ethnic-group-in-the-u-s/.Google Scholar There is significant heterogeneity of cultural beliefs and end-of-life care intensity preferences among ethnic subgroups within this population.2Hsiung, Yi-fang Yvonne RN, MS; Ferrans, Carol Estwing PhD, RN, FAAN. Recognizing Chinese Americans' Cultural Needs in Making End-of-Life Treatment Decisions. Journal of Hospice & Palliative Nursing 9(3):p 132-140, May 2007. | DOI: 10.1097/01.NJH.0000269993.13625.49Google Scholar, 3Li L.B. Clinical review: Ethics and end-of-life care for critically ill patients in China.Crit Care. 2013 Dec 4; 17 (PMID: 24313980; PMCID: PMC4057346): 244https://doi.org/10.1186/cc13140Crossref Scopus (29) Google Scholar, 4Holland A.T. Palaniappan L.P. Problems with the collection and interpretation of Asian-American health data: omission, aggregation, and extrapolation.Ann Epidemiol. 2012 Jun; 22 (PMID: 22625997; PMCID: PMC4324759): 397-405https://doi.org/10.1016/j.annepidem.2012.04.001Crossref PubMed Scopus (191) Google Scholar We sought to investigate the incidence of kidney replacement therapy (KRT) use at end-of-life (EOL) among critically-ill Chinese American and White American decedents at a single urban tertiary medical center located in the Northeastern United States . Chinese American and White American intensive care unit (ICU) decedents between 2014 and 2020 were previously identified from the electronic health record and matched using a 1:1 ratio on year of ICU admission, sex, age, and reason for ICU admission. Chinese Americans were defined as individuals whose documented race was Asian with language proficiency in Chinese, Mandarin, Cantonese, or Taishanese, while White Americans were defined as individuals whose race was documented as non-Hispanic White. Matches were excluded from analyses if either individual received KRT preceding time of ICU admission. We determined the incidence of KRT use, and then examined the association of Chinese American vs White American and KRT use at EOL using two conditional logistic regression models: 1). unadjusted; and 2). model 1, adjusted for illness severity as assessed by Charlson comorbidity index score5Charlson M.E. Pompei P. Ales K.L. MacKenzie C.R. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.J Chronic Dis. 1987; 40 (PMID: 3558716): 373-383https://doi.org/10.1016/0021-9681(87)90171-8Abstract Full Text PDF PubMed Scopus (37650) Google Scholar and serum creatinine at time of admission. Interpreter services were available for the duration of the study. Informed consent was waived and the study was exempt from ethics review because the study was not deemed human subjects research. Forty ICU decedents were excluded for prior recipience of KRT (i.e. were on maintenance outpatient dialysis prior to admission) , resulting in a final cohort of 266 patients. Mean (SD) age of Chinese American and White American decedents was 79 ± 11 and 77 ± 10 years, with median serum creatinine at time of ICU admission of 1.49 (IQR, 1.04-2.20) and 1.31 (IQR, 0.89-2.17) mg/dL, respectively. Fourteen (10.5%) Chinese American and 130 (97.7%) White American decedents had English documented as their primary language. Prevalent comorbidities, receipt of invasive mechanical ventilation, and rates of advanced care planning at time of ICU admission were similar between the two groups (Table 1).Table 1Characteristics of the Patients at Baseline by Race, EthnicityWhite AmericanChinese AmericanN = 133N = 133Age — yr*77.44 ± 10.0779.38 ± 10.75Male sex — no. (%)55 (41.4)56 (42.1)English as Primary Language — no. (%)130 (97.7)14 (10.5)Year of admission — no. (%)20144 (3.0)5 (3.8)201521 (15.8)23 (17.3)201624 (18.0)21 (15.8)201724 (18.0)24 (18.0)201824 (18.0)21 (15.8)201922 (16.5)23 (17.3)202014 (10.5)16 (12.0)Admitting diagnosis — no. (%)Renal3 (2.3)4 (3.0)Cardiothoracic surgery3 (2.3)3 (2.3)Cardiovascular33 (24.8)33 (24.8)Gastrointestinal12 (9.0)12 (9.0)Metabolic2 (1.5)2 (1.5)Neoplasm6 (4.5)6 (4.5)Neurological5 (3.8)5 (3.8)Postoperative1 (0.8)1 (0.8)Respiratory26 (19.5)25 (18.8)Sepsis25 (18.8)24 (18.0)Trauma/Hemorrhage17 (12.8)18 (13.5)Intensive Care Unit type — no. (%)MICU51 (38.3)54 (40.6)SICU28 (21.1)27 (20.3)CCU26 (19.5)30 (22.6)NCCU28 (21.1)22 (16.5)Charlson Comorbidity Index (IQR) †3 (2.0 – 4.0)3 (1.0 – 4.0)Length of stay (IQR) — days7 (3.0 – 15.0)6 (3.0 – 10.0)Serum creatinine (IQR) — mg/dl1.31 (0.89 – 2.17)1.49 (1.04 – 2.20)Estimated glomerular filtration rate — ml/min/1.73 m247.93 ± 27.343.84 ± 27.0Invasive Mechanical Ventilation on admission — no. (%)97 (36.5)93 (35.0)Comorbidity — no. (%)Any CKD21 (15.8)22 (16.5)CKD 315 (11.3)11 (8.3)CKD 45 (3.8)9 (6.8)CKD 51 (0.8)2 (1.5)Dementia15 (11.3)15 (11.3)Cancer12 (9.0)21 (15.8)CHF47 (35.3)36 (27.1)COPD30 (22.6)26 (19.5)Advanced Care Planning on ICU admission — no. (%)DNR29 (10.9)25 (9.4)DNI20 (7.5)19 (7.1)HCP36 (13.5)35 (13.2)* Plus–minus values are means ± SD† Score ranges between 1-6, with higher scores indicating lower 10-year survivalAbbreviations: MICU, Medical Intensive Care Unit; SICU, Surgical Intensive Care Unit; CCU, Critical Care Unit; NCCU, Neurocritical Care Unit; CKD, Chronic Kidney Disease; CHF, Congestive Heart Failure; COPD, Chronic Obstructive Pulmonary Disease; DNR, Do Not Resuscitate; DNI, Do Not Intubate; HCP, Health Care Proxy Open table in a new tab * Plus–minus values are means ± SD † Score ranges between 1-6, with higher scores indicating lower 10-year survival Abbreviations: MICU, Medical Intensive Care Unit; SICU, Surgical Intensive Care Unit; CCU, Critical Care Unit; NCCU, Neurocritical Care Unit; CKD, Chronic Kidney Disease; CHF, Congestive Heart Failure; COPD, Chronic Obstructive Pulmonary Disease; DNR, Do Not Resuscitate; DNI, Do Not Intubate; HCP, Health Care Proxy Thirty-eight of 266 ICU decedents received KRT (cumulative incidence 14.3% of entire cohort, 10.5% and 18.0% of Chinese American and White Americans, respectively). The unadjusted odds of KRT use among Chinese American ICU decedents as compared to White American ICU decedents was 0.50 (95% CI, 0.23, 1.07), which did not change significantly after adjusting for baseline illness severity and kidney function on admission (OR 0.42 [95% CI, 0.15, 1.13]) (Table 2).Table 2Unadjusted and Adjusted Odds Ratios for Kidney Replacement Therapy UseWhite AmericanChinese AmericanN133133Events2414Total days follow-up14121093Event rate per 1000 patient-days17.0012.81Unadjusted OR (95% CI)ref0.50 (0.23, 1.07)Model 1* OR (95% CI)ref0.42 (0.15, 1.13)*Model 1 adjusted for Charlson comorbidity index and admission serum creatinineAbbreviations: OR, Odds Ratio; CI, Confidence Interval Open table in a new tab *Model 1 adjusted for Charlson comorbidity index and admission serum creatinine Abbreviations: OR, Odds Ratio; CI, Confidence Interval Here we report, the first ever evaluation of KRT use at EOL among Chinese American ICU decedents at a single urban tertiary medical center. We observed that Chinese American ICU decedents received KRT at an absolute incidence rate of 4.19 events per 1000 patient-days lower than White Americans, and had 58% lower odds of receiving KRT in adjusted analyses, despite comparable illness severity and EOL care intensity preferences (Table 2). Our findings suggest practice differences between these two populations, which may be driven by individual (clinician bias, patient-preference), institutional, societal factors (culture, language discordance), or a combination thereof. Our findings are surprisingly at odds with previously described EOL care intensity trends observed among Asian Americans, including higher rates of invasive mechanical ventilation use, in-hospital death, and decreased hospice use as compared to White Americans.6Smith A.K. Earle C.C. McCarthy E.P. Racial and ethnic differences in end-of-life care in fee-for-service Medicare beneficiaries with advanced cancer.J Am Geriatr Soc. 2009 Jan; 57 (Epub 2008 Nov 21. PMID: 19054185; PMCID: PMC2948958): 153-158https://doi.org/10.1111/j.1532-5415.2008.02081.xCrossref PubMed Scopus (158) Google Scholar, 7Wang S.Y. Hsu S.H. Huang S. Doan K.C. Gross C.P. Ma X. Regional Practice Patterns and Racial/Ethnic Differences in Intensity of End-of-Life Care.Health Serv Res. 2018 Dec; 53 (Epub 2018 Jun 27. PMID: 29951996; PMCID: PMC6232508): 4291-4309https://doi.org/10.1111/1475-6773.12998Crossref Scopus (8) Google Scholar, 8Wang S.Y. Hsu S.H. Aldridge M.D. Cherlin E. Bradley E. Racial Differences in Health Care Transitions and Hospice Use at the End of Life.J Palliat Med. 2019 Jun; 22 (Epub 2019 Jan 4. PMID: 30615546; PMCID: PMC6533794): 619-627https://doi.org/10.1089/jpm.2018.0436Crossref Scopus (23) Google Scholar, 9Jia Z. Leiter R.E. Sanders J.J. Sullivan D.R. Gozalo P. Bunker J.N. Teno J.M. Asian American Medicare Beneficiaries Disproportionately Receive Invasive Mechanical Ventilation When Hospitalized at the End-of-Life.J Gen Intern Med. 2022 Mar; 37 (Epub 2021 Apr 26. PMID: 33904035; PMCID: PMC8075023): 737-744https://doi.org/10.1007/s11606-021-06794-6Crossref Scopus (7) Google Scholar Prior studies have attributed higher intensity of care at EOL utilized by Chinese Americans to: 1.) value systems that promote filial piety; 2.) expectations of family that may indirectly obligate caregivers to sustain the lives of loved ones; and 3.) avoidance of advanced care planning due to cultural views on death.2Hsiung, Yi-fang Yvonne RN, MS; Ferrans, Carol Estwing PhD, RN, FAAN. Recognizing Chinese Americans' Cultural Needs in Making End-of-Life Treatment Decisions. Journal of Hospice & Palliative Nursing 9(3):p 132-140, May 2007. | DOI: 10.1097/01.NJH.0000269993.13625.49Google Scholar,3Li L.B. Clinical review: Ethics and end-of-life care for critically ill patients in China.Crit Care. 2013 Dec 4; 17 (PMID: 24313980; PMCID: PMC4057346): 244https://doi.org/10.1186/cc13140Crossref Scopus (29) Google Scholar We hypothesize that our findings may be attributed, in part, to physician-patient language discordance, which has previously associated with inadequate ascertainment of patient preferences and worse health outcomes.10Divi C. Koss R.G. Schmaltz S.P. Loeb J.M. Language proficiency and adverse events in US hospitals: a pilot study.Int J Qual Health Care. 2007 Apr; 19 (Epub 2007 Feb 2. PMID: 17277013): 60-67https://doi.org/10.1093/intqhc/mzl069Crossref PubMed Scopus (424) Google Scholar However, we were unable to evaluate for an interaction between patients’ race and ethnicity, primary language, and KRT utilization due to small sample size. The major strength of this study is the evaluation of EOL care utilization within a specific ethnic category, Chinese American, disaggregated from the US federal race category “Asian,” which acknowledges the heterogeneity of cultural preferences and clinical outcomes observed among different Asian American groups.4Holland A.T. Palaniappan L.P. Problems with the collection and interpretation of Asian-American health data: omission, aggregation, and extrapolation.Ann Epidemiol. 2012 Jun; 22 (PMID: 22625997; PMCID: PMC4324759): 397-405https://doi.org/10.1016/j.annepidem.2012.04.001Crossref PubMed Scopus (191) Google Scholar Limitations of this study include small sample size, single-center nature, sparse sociodemographic data, non-self-reported race and ethnicity, and the potential for residual confounding by illness severity at time of ICU admission. In conclusion, we observed that critically-ill Chinese American decedents were less likely to receive KRT as compared to White American decedents at EOL at a single tertiary care center. This finding highlights the need for multi-center evaluation, with additional identification of clinician- and patient-specific factors to delineate cultural preferences from health disparities and promote equitable, culturally sensitive care in an increasingly diverse America.
Source: Kidney Medicine
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $2,400
OpenAlex ID: W4393195369