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 impli- cation of these findings is that variation exists in the efficiency and quality of end of life care delivered to ethnic minorities.