The Impact of Race on Advanced Care Planning: Results of a Quality Improvement Project

Aaron Lear; Michael Arnold; Rachida Bouhenni; Caroline Mangira; Megan Adelman; Kevin Baldie; Estee George

doi:10.3122/jabfm.2025.250310R1

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Table 1. Associations Between Patient Characteristics and ACP

Characteristic	All patients (n = 22,372)	ACP (n = 7,678)	No ACP (n = 14,694)	P-⁠value
Race Black Other White	2,471 (11.19) 316 (1.43) 19,295 (87.38)	723 (29.26) 81 (25.63) 6,792 (35.20)	1,748 (70.74) 235 (74.37) 12,503 (64.80)	< 0.0001
Sex Female Male	11,510 (51.45) 10,861 (48.55)	4,079 (35.44) 3,598 (33.13)	7,431 (64.56) 7,263 (66.87)	0.0003
Age	74.10 (69.36-80.46)	76.23 (71.0-83.38)	73.03 (68.7-79.03)	< .0001
Ethnicity Hispanic Not Hispanic	101 (0.47) 21,594 (99.53)	23 (22.77) 7,488 (34.68)	78 (77.23) 1,4106 (65.32)	0.0121
Marital Status Divorced Married Other Single Widowed	2,414 (10.87) 12,229 (55.07) 160 (0.72) 2,908 (13.09) 4,497 (20.25)	859 (35.58) 3,741 (30.59) 58 (36.25) 947 (32.57) 2,023 (44.99)	1,555 (64.42) 8,488 (69.41) 102 (63.75) 1,961 (67.43) 2,474 (55.01)	< .0001
Religion Catholic Other* Other Christian Traditional Protestant Non-Christian World Religions^	3,952 (28.45) 311 (2.24) 3,381 (24.34) 5,961 (42.92) 285 (2.05)	1,490 (37.70) 121 (38.91) 1,234 (36.50) 2,375 (39.84) 108 (37.89)	2,462 (62.30) 190 (61.09) 2,147 (63.50) 3,586 (60.16) 177 (62.11)	0.0235
Insurance Coverage Medicaid Medicare Private Self-pay	1,171 (5.29) 19,496 (88.01) 1,478 (6.67) 8 (0.04)	364 (31.08) 6,801 (34.88) 414 (28.01) 2 (25.00)	807 (68.92) 12,695 (65.12) 1,064 (71.99) 6 (75.00)	< .0001
Updated Charlson Index < 2 ≥ 2	18,424 (82.35) 3,948 (17.65)	5,478 (29.73) 2,200 (55.72)	12,946 (70.27) 1,748 (44.28)	< .0001

Notes: Statistics presented as n (%) or median (Q1-Q3). Percentages do not reflect missing values. Abbreviations: ACP = Advanced care planning. *Other = self-identified by patients at registration on electronic health record. ^Non-Christian World Religions includes Buddhism, Hinduism, Islam, Judaism.

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Table 2. Multiple Logistic Regression Estimates for Effect of Race on Advanced Care Planning After Controlling for Other Demographic Characteristics, (n = 21,771)

Characteristic	Adjusted Odds Ratio (95% Confidence Interval)	P-⁠value
Race Black vs White Other vs White	0.64 (0.58-0.71) 0.63 (0.48-0.82)	< .0001 0.0007
Sex Female vs Male	1.02 (0.96-1.08)	0.6339
Age (Decades)	1.48 (1.42-1.54)	< .0001
Marital Status Divorced vs Married Other vs Married Single vs Married Widowed vs Married	1.26 (1.14-1.39) 1.40 (0.99-1.96) 1.12 (1.02-1.23) 1.35 (1.24-1.46)	< .0001 0.0541 0.0149 < .0001
Insurance Coverage Medicaid vs Private Medicare vs Private Self-pay vs Private	1.02 (0.85-1.22) 1.10 (0.97-1.24) 1.06 (0.20-5.53)	0.8260 0.1401 0.9467
Updated Charlson Index	1.32 (1.30-1.35)	< .0001

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Table 3. Bivariate Associations Between Patient Characteristics and Sub-Group ACP Discussion with Clinician (n = 22,372)

Characteristic	ACP Discussion with clinician (n = 2298)	No ACP Discussion with clinician (n = 20074)	P-⁠value
Race Black Other White	315 (12.75) 28 (8.86) 1,925 (9.98)	2,156 (87.25) 288 (91.14) 17,370 (90.02)	< 0.0001
Gender Female Male	1,247 (10.83) 1,051 (9.68)	10,263 (89.17) 9,810 (90.32)	0.0004
Age	78.26 (72.06-85.39)	73.75 (69.15-79.90)	< .0001
Ethnicity Hispanic Not Hispanic	11 (10.89) 2,241 (10.38)	90 (89.11) 19,353 (89.62)	0.8660
Marital Status Divorced Married Other Single Widowed	253 (10.48) 1,013 (8.28) 15 (9.38) 307 (10.56) 691 (15.37)	2,161 (89.52) 11,216 (91.72) 145 (90.63) 2,601 (89.44) 3,806 (84.63)	< .0001
Religion Catholic Other* Other Christian Traditional Protestant Non-Christian World Religions^	398 (10.07) 28 (9.00) 350 (10.35) 705 (11.83) 37 (12.98)	3,554 (89.93) 283 (91.00) 3,031 (89.65) 5,256 (88.17) 248 (87.02)	0.0215
Insurance Status Medicaid Medicare Private Self-Pay	151 (12.89) 1,988 (10.20) 117 (7.92) 1 (12.50)	1,020 (87.11) 17,508 (89.80) 1,361 (92.08) 7 (87.50)	0.0005
CCI	1.0 (0.0-3.0)	0.0 (0.0-0.0)	< .0001
Updated CCI Score < 2 ≥ 2	1,269 (6.89) 1,029 (26.06)	17,155 (93.11) 2,919 (73.94)	< .0001
Advance Directive and/⁠POA No Yes	1,232 (7.74) 1,066 (16.54)	14,694 (92.26) 5,380 (83.46)	< .0001

Notes: Statistics presented as n (%) or median (Q1-Q3). Percentages do not reflect missing values. *Other = self-identified by patients at registration on electronic health record. ^Non-Christian World Religions includes Buddhism, Hinduism, Islam, Judaism.

Abbreviations: ACP = advanced care planning, POA = healthcare power of attorney, CCI = updated Charlson comorbidity index.

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Table 4. Bivariate Associations Between Patient Characteristics and Sub-Group Advance Directives and/POA, (n = 22,372)

Characteristic	Advance Directive and/POA (n = 6446)	No Advance Directive/POA (n = 15926)	P-⁠value
Race Black Other White	536 (21.69) 64 (20.25) 5,780 (29.96)	1,935 (78.31) 252 (79.75) 13,515 (70.04)	< 0.0001
Gender Female Male	3,422 (29.73) 3,023 (27.83)	8,088 (70.27) 7,838 (72.17)	0.0017
Age	76.13 (70.91-83.10)	73.30 (68.84-79.43)	< .0001
Ethnicity Hispanic Not Hispanic	18 (17.82) 6,290 (29.13)	83 (82.18) 15,304 (70.87)	0.0125
Marital Status Divorced Married Other Single Widowed	730 (30.24) 3,139 (25.67) 48 (30.00) 800 (27.51) 1,682 (37.40)	1,684 (69.76) 9,090 (74.33) 112 (70.00) 2,108 (72.49) 2,815 (62.60)	< .0001
Religion Catholic Other* Other Christian Traditional Protestant Non-Christian World Religion^	1,313 (33.22) 104 (33.44) 1,052 (31.12) 2,029 (34.04) 92 (32.28)	2,639 (66.78) 207 (66.56) 2,329 (68.88) 3,932 (65.96) 193 (67.72)	0.0748
Insurance Status Medicaid Medicare Private Self-Pay	283 (24.17) 5,747 (29.48) 340 (23.00) 1 (12.50)	888 (75.83) 13,749 (70.52) 1,138 (77.00) 7 (87.50)	< .0001
Updated CCI Score < 2 ≥ 2	4,738 (25.72) 1,708 (43.26)	13,686 (74.28) 2,240 (56.74)	< .0001
Advanced Care Planning Discussion with Clinician No Yes	5,380 (26.80) 1,066 (46.39)	14,694 (73.20) 1,232 (53.61)	< .0001

Notes: Percentages do not reflect missing values. Statistics presented as n (row%) or median (Q1-Q3). *Other = self-identified by patients at registration on electronic health record; ^Non-Christian World Religions includes Buddhism, Hinduism, Islam, Judaism.

Abbreviations: POA = healthcare power of attorney, CCI = updated Charlson comorbidity index.