RESUMO
BACKGROUND: Black patients are more likely than white patients to prefer and receive more life-sustaining interventions in advanced stages of disease. However, little is known about potential racial differences in use of mechanical ventilation (MV), and the newer modality of noninvasive ventilation (NIV), in treatment of chronic obstructive pulmonary disease (COPD). OBJECTIVE: To determine if rates of MV and NIV use differ among black and white patients admitted to Veterans Administration (VA) hospitals for COPD exacerbation. RESEARCH DESIGN: Retrospective cohort analysis of VA database FY2003 to FY2005 including 153 hospitals nationwide. SUBJECTS: All black (n = 479) and white (n = 31,537) patients admitted with COPD exacerbation. MEASURES: Ventilation use during hospitalization as identified by ICD-9-CM codes for MV and NIV. Hierarchical logistic regression compared rates of MV or NIV use among black and white patients, adjusting for patient characteristics and accounting for hospital-level variation. RESULTS: Unadjusted rates of MV were higher in black patients than in white patients (4.1% vs. 3.0%; P < 0.001), but similar for NIV (6.0% vs. 6.1%; P = 0.65). The adjusted odds of MV for black patients relative to white patients remained higher (OR = 1.27, 95% CI: 1.01-1.54; P < 0.01) while the adjusted odds of NIV remained similar (OR = 0.94, 95% CI: 0.82-1.08; P = 0.38). CONCLUSIONS: Black patients with COPD exacerbation in VA hospitals are more likely than white patients to receive MV, and this difference is not explained by available clinical or demographic variables. By contrast, black and white patients are equally likely to receive NIV. These findings suggest that unmeasured factors, such as patient preferences or disease severity, may be affecting the use of MV in this setting and therefore warrant further investigation.
Assuntos
Negro ou Afro-Americano/estatística & dados numéricos , Pressão Positiva Contínua nas Vias Aéreas/estatística & dados numéricos , Disparidades em Assistência à Saúde , Hospitais de Veteranos/normas , Cuidados para Prolongar a Vida/estatística & dados numéricos , Doença Pulmonar Obstrutiva Crônica/etnologia , Doença Pulmonar Obstrutiva Crônica/terapia , Respiração Artificial/estatística & dados numéricos , Insuficiência Respiratória/etnologia , Insuficiência Respiratória/terapia , População Branca/estatística & dados numéricos , Fatores Etários , Idoso , Estudos de Coortes , Bases de Dados Factuais , Feminino , Acessibilidade aos Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Qualidade da Assistência à Saúde , Insuficiência Respiratória/etiologia , Fatores Sexuais , Estados Unidos , United States Department of Veterans Affairs/normasRESUMO
Goals of care are often mentioned as an important component of end-of-life discussions, but there are diverse assessments regarding the type and number of goals that should be considered. To address this lack of consensus, we searched MEDLINE (1967-2007) for relevant articles and identified the number, phrasing, and type of goals they addressed. An iterative process of categorization resulted in a list of 6 practical, comprehensive goals: (1) be cured, (2) live longer, (3) improve or maintain function/quality of life/ independence, (4) be comfortable, (5) achieve life goals, and (6) provide support for family/caregiver. These goals can be used to articulate goal-oriented frameworks to guide decision making toward the end of life and thereby harmonize patients' treatment choices with their values and medical conditions.