Ethnic Differences in In-Hospital Place of Death Among Older Adults in California Effects of Individual and Contextual Characteristics and Medical Resource Supply

Background: Substantial ethnic differences have been reported in the probability that death will occur in a hospital setting rather than at home, in a hospice, or in a nursing home. To date, no study has investigated the role of both individual characteristics and contextual characteristics, including local health care environments, to explain ethnic differentials in end-of-life care. Objectives: The study purpose is to examine ethnic differences in the association between death as a hospital in-patient and individual and contextual characteristics, as well as medical resource supply. Research Design: This study employed a secondary data analysis. Subjects: We used data from the California Death Statistical Master file for the years 1999-2001, which included 472,382 complete cases. These data were geocoded and linked to data from the US Census Bureau and the American Hospital Association. Results: Death as an in-patient was most common for Asian (54%) and Hispanic immigrants (49%) and least common for non-Hispanic whites (36%) and US-born Asians (41%). Medical resource supply variables are of considerable importance in accounting for ethnic differentials in the probability of dying in a hospital. Residual differences in in-hospital site of death were largest for immigrant populations. Conclusions: There are sizeable ethnic differentials in the probability that a death will occur in a hospital in California. These differences are substantially mediated by sociodemographic characteristics of the decedent and local medical care supply. One implication of these findings is that variation exists in the efficiency and quality of end of life care delivered to ethnic minorities.