The Association of Chinese Ethnicity and Language Preference with Advance Directive Completion Among Older Patients in an Integrated Health System.

BACKGROUND: Little is known about possible differences in advance directive completion (ADC) based on ethnicity and language preference among Chinese Americans on a regional level. OBJECTIVE: To understand the association of ethnicity and language preference with ADC among Chinese Americans. DESIGN: Retrospective cohort analysis with direct standardization. PARTICIPANTS: A total of 31,498 Chinese and 502,991 non-Hispanic White members enrolled in Kaiser Permanente Northern California during the entire study period between 2013 and 2017 who were 55 or older as of January 1, 2018. MAIN MEASURES: We compared the proportion of ADC among non-Hispanic White and Chinese patients, and also analyzed the rates according to language preference within the Chinese population. We calculated ADC rates with direct standardization using covariates previously found in literature to be significant predictors of ADC such as age and utilization. KEY RESULTS: Among Chinese members, 60% preferred English, 16% preferred another language without needing an interpreter, and 23% needed an interpreter. After standardizing for age and utilization, non-Hispanic Whites were more than twice as likely to have ADC as Chinese members (20.6% (95% confidence interval (CI): 20.5-20.7%) vs. 10.0% (95% CI: 9.6-10.3%), respectively). Among Chinese members, there was an inverse association between preference for a language other than English and ADC (13.3% (95% CI: 12.8-13.8%) if preferring English, 6.1% (95% CI: 5.4-6.7%) if preferring non-English language but not needing an interpreter, and 5.1% (95% CI: 4.6-5.6%) if preferring non-English language and needing an interpreter). CONCLUSIONS: Chinese members are less likely to have ADC relative to non-Hispanic White members, and those preferring a language other than English are most affected. Further studies can assess reasons for lower ADC among Chinese members, differences in other Asian American populations, and interventions to reduce differences among Chinese members especially among those preferring a language other than English.

Advance Directive Completion Among Black Adults Within a Community-Based Integrated Health Care System.

ObjectivesThe study was conducted to estimate the prevalence of advance directive (AD) completion among Black adults vs non-Hispanic White adults within Kaiser Permanente Northern California integrated health system that includes access to outpatient advance care planning (ACP) specialists and to identify medical services utilization patterns and societal factors that could influence ACP engagement. DesignThe study was carried out through retrospective analysis of electronic health record data of active Kaiser Permanente Northern California members from January 1, 2013 to December 31, 2017, who were age 55 and older, and represented 572,466 active members, of which 11.7% were Black adults. The primary objective was AD completion comparing Black adults to non-Hispanic White adults. Demographic data included age, sex, comorbidities (Charlson comorbidity score ≥ 3) and medical services utilization (inpatient, outpatient, and emergency department [ED] use). Sociodemographic data derived from census data that include census block demographics and head of household educational attainment were utilized. ResultsBlack adults were younger, but had a higher burden of comorbidities (Charlson comorbidity score ≥ 3, 25.3% vs 19.3%) and were more likely to have multiple ED visits (6.7% vs 3.3%) compared to non-Hispanic White adults. The crude AD completion rate was lower among Black adults (10.0% vs 20.3%), and after adjusting for age and health system service area, the difference remained largely unchanged (11.7% vs 20.3%) compared to non-Hispanic White adults. ConclusionsAmong Kaiser Permanente Northern California members with access to outpatient ACP specialists, Black adults were only half as likely to complete an AD. This disparity was only slightly attenuated when standardized for age and health system service area. In addition, Black adults were also less likely to use outpatient services and more likely to use ED services.