The Black and White of Invasive Mechanical Ventilation in Advanced Dementia

BACKGROUND/OBJECTIVES: Over the past decade, feeding tube use in nursing home residents with advanced dementia has declined by 50% among white and black patients. Little is known about whether a similar reduction has occurred in other invasive interventions, such as mechanical ventilation. DESIGN: Retrospective cohort study. SETTING: Acute-care hospitals in the United States. PARTICIPANTS: Medicare beneficiaries with advanced dementia who previously resided in a nursing home and were hospitalized between 2001 and 2014 with pneumonia and/or septicemia and of either black or white race. MEASUREMENT: Invasive mechanical ventilation (IMV), as identified by International Classification of Diseases (ICD) procedure codes. Two multivariable logistic regression models examined the association between race and the likelihood of receiving IMV, adjusting for patients' demographics, physical function, and comorbidities. A hospital fixed-effects model examined the association of race within a hospital, whereas a random-effects logistic model was used to estimate the between-hospital variation in the probability of receiving IMV and examine the overall association of race and use of IMV. RESULTS: Between 2001 and 2014, 289,017 patients with advanced dementia were hospitalized for pneumonia or septicemia. Use of IMV increased from 3.7% to 12.1% in white patients and from 8.6% to 21.8% in blacks. Among those ventilated, 1-year mortality rates remained high, at 82.7% for whites and 84.2% for blacks dying in 2013. Compared with whites, blacks had a higher odds of receiving IMV in the fixed-effects (within-hospital) model (adjusted odds ratio (AOR) = 1.34; 95% confidence interval (CI) = 1.29–1.39) and in the random-effects (between-hospital) model (AOR = 1.46; 95% CI = 1.40–1.51). CONCLUSION: IMV use in patients with advanced dementia has increased substantially, with black patients having a larger increase than whites, based, in part, on the hospitals where black patients receive care.