Social and health determinants of end-of-life care quality
Creators: name: Luth, Elizabeth Anne
Publisher: name: No Publisher Supplied
Year: 2017

description: Providing high-quality end-of-life (EOL) care to the nearly 1.9 million older adults who die each year in the U.S. is a pressing concern for policy makers and health care professionals. Medical and public health literature examines the quality of care for dying patients by considering a single measure or a handful of measures separately and in an atheoretical manner. I conduct latent class analysis (LCA) on four waves of National Health and Aging Trends Study data to develop three statistically and conceptually distinct subtypes of proxy reported end-of-life (EOL) care quality that consider multiple dimensions of care simultaneously. I find that between 20 and 25 percent of proxies report that decedents experience EOL characterized by unwanted symptoms and low quality care.  The first analytic chapter uses these categories as an outcome measure to explore the extent to which social determinants of health and mortality extend to proxy perceptions of EOL care quality for 1,046 decedents. I find that the three primary axes of disadvantage in the U.S.-gender, race/ethnicity, and socioeconomic status-do not predict proxy perceptions of EOL care quality. However, hospice involvement, diagnosis with serious illness, dying in a location other than home, and more frequent hospitalization predict perceptions of care characterized by the presence of unwanted symptoms and poorer assessments on health care encounters and personal care measures. These findings have implications for how EOL care is assessed and suggest that policies to improve EOL care should target place of death, hospice involvement, and the needs of acutely and chronically ill persons.  The second analytic chapter analyzes how proxy reporters’ evaluations of EOL care vary based on the decedent’s advance care planning (ACP) behavior, attitudes towards religious participation, and social characteristics (race/ethnicity, education, and sex). ACP does not predict EOL care quality using a multidimensional measure of quality. Greater importance of religious participation is associated with higher quality EOL care, and this relationship is stronger among individuals who complete ACP. Proxies for non-Hispanic whites report symptomatic, lower quality EOL care. Proxies for more religious decedents may associate these beliefs with these decedents’ increased acceptance of EOL and satisfaction with care. To the extent close family members share decedents’ religious attitudes, knowing a loved one’s preferences for EOL care may also facilitate increased satisfaction with care.  The third analytic chapter explores how proxy reporters’ evaluations of EOL care vary based on the proxy reporters’ characteristics (familiarity with care, relationship to decedent). Proxy reporter’s familiarity with the decedent’s EOL care and relationship to the decedent predict their assessments of care quality. Results suggest caregiving roles and motivations for providing positive assessments should be carefully considered in understanding EOL care assessments, particularly for wives and paid caregivers.   This dissertation uses LCA, a methodological approach to assessing EOL care quality that simultaneously accounts for multiple measures of care and how they co-occur among a sample of older adults. LCA provides an alternative method for assessing how multiple pieces of information move together and is potentially useful for understanding care for a variety of scenarios and settings. Attention to how social characteristics and processes relate to variation in perceptions of care among different subgroups can support practitioners and policy makers in targeting their efforts to improve care in a way that does not create or exacerbate disparities.