Date of Award

2019

Degree Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Graduate Group

Nursing

First Advisor

Salimah H. Meghani

Abstract

Acute care near end-of-life (EOL) is associated with lower quality of life and higher EOL costs, which are associated with worse quality death. Goals-of-care (GOC) discussions are associated with lower costs. Racial/ethnic minorities are less likely to have these discussions. It is unknown how costs and healthcare utilization differ by race/ethnicity following inpatient GOC discussion or how risk factor profiles are associated with discussion timing. Primary aims included: (1) Exploring associations among EOL discussions, costs, and proxies for costs (healthcare utilization, place of death) in persons with advanced cancer near EOL (Chapter 2); (2) Assessing future acute care costs and healthcare utilization among Whites and African Americans with serious illness who either did or did not have inpatient palliative care consultation to discuss GOC (“PCC”) (n = 35,154; PCC: n= 1,197; non-PCC: 33,957) (Chapter 3); and (3) Examining risk factor profiles associated with timing of PCC before death (PCC 0-14 days before death, n = 612; PCC 15-60 days before death, n = 292; PCC more than 60 days before death, n = 237) among deceased persons who received PCC (Chapter 4). Secondary analysis included demographic, clinical, and financial data of patients 18+ admitted to a large, urban, academic medical center July 1, 2014 to October 31, 2016. Patients admitted for childbirth or rehabilitation, patients hospitalized at the end of the study, and for Chapter 3 patients who died during the admission they first received PCC were excluded. A systematic review (Chapter 2) found EOL discussions were associated with less acute and intensive care, greater hospice use, and lower EOL costs among advanced cancer patients. Propensity score matching (Chapter 3) showed PCC was associated with increased discharge to hospice among African American and White patients with PCC; and lower 30-day readmissions, fewer future days hospitalized, and lower future acute care costs (average $8,704 per patient) for Whites with PCC, but not African Americans with PCC. Multinomial logistic regression and classification and regression tree modeling (Chapter 4) showed a complex set of variable interactions were associated with PCC timing before death. Results imply need for investment in PCC across racial groups.

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