Invasive mechanical ventilation at end of life may be more common in Asian Americans

Researchers used a 20% random sample of Medicare fee-for-service beneficiaries to compare receipt of invasive mechanical ventilation among Asian American and White patients hospitalized in the last 30 days of life.

Asian Americans may be more likely to receive invasive mechanical ventilation at the end of life, according to a recent study.

In a population-based retrospective cohort study, researchers used a 20% random sample of Medicare fee-for-service beneficiaries to compare receipt of invasive mechanical ventilation among Asian American and White patients. All beneficiaries were age 66 years or older, had died between 2000 to 2017, and had been hospitalized in the last 30 days of life. Data on ethnicity were determined as by the Social Security Administration. Invasive mechanical ventilation was identified using validated procedural codes, and its use was compared between Asian American and White fee-for-service decedents using random-effects logistic regression analysis, with adjustments for sociodemographics, admitting diagnosis, comorbid conditions, and secular trends. The study results were published April 26 by the Journal of General Internal Medicine.

The study included 2.1 million White patients (54.5% women, mean age 82 years) and 28,328 Asian American patients (50.8% women, mean age 82.6 years). The latter group had an adjusted odds ratio of 1.42 (95% CI, 1.38 to 1.47) for invasive mechanical ventilation compared with White patients. Subanalyses by admitting diagnosis also found higher adjusted odds ratios for invasive mechanical ventilation among Asian American patients versus White patients: 1.32 (95% CI, 1.15 to 1.51) for cancer, 1.75 (95% CI, 1.47 to 2.08) for congestive heart failure, 1.93 (95% CI, 1.70 to 2.20) for dementia, and 2.25 (95% CI, 1.76 to 2.89) for chronic obstructive pulmonary disease. In addition, Asian Americans had higher rates of death in the hospital rather than outside (62.1% vs. 51.4%) and ICU admission (52.7% vs. 40.1%) and lower rates of hospice enrollment overall (22.5% vs. 31.6%) and in the last three days of life (8.9% vs. 13.4%) when compared with White patients.

The researchers noted that their findings may not be generalizable to younger patients and that they did not have data on patient or family preferences for end-of-life care, among other limitations. They concluded that that older Asian American patients appear more likely than White patients to receive high-intensity care during hospitalization at the end of life, including invasive mechanical ventilation and ICU care; more likely to die in the hospital; and less likely to receive hospice care. They stressed that few studies have been done on end-of-life care in Asian American patients and said more research is needed in this area.

“While observed differences are partly explained by sociodemographics and hospital-level variability, they may also signal the presence of underlying health disparities,” the authors wrote. “Further research is needed to understand these potential [end-of-life] care disparities by exploring patient/caregiver shared decision-making preferences, evaluating the availability and effectiveness of palliative care services, and disaggregating Asian Americans into sub-populations.”