ORIGINAL RESEARCH
Aaron Lear, MD, MSc, CAQ; Michael Arnold, DO; Rachida Bouhenni, PhD; Caroline Mangira, MPH; Megan Adelman, PharmD; Kevin Baldie, MD; Estee George, PhD
Corresponding Author: Aaron Lear, MD, MSc, CAQ; Center for Family Medicine, Cleveland Clinic Akron General.
Email: leara@ccf.org
DOI: 10.3122/jabfm.2025.250310R1
Keywords: Advance Care Planning, Aging, Cross-Cultural Comparison, Diversity, End Of Life Care, Health Inequities, Quality Improvement, Retrospective Studies
Dates: Submitted: 08-06-2025; Revised: 10-24-2025; Accepted: 11-10-2025
Status: In Press.
INTRODUCTION: Research suggests racial disparities affect the likelihood that patients engage in advanced care planning (ACP). With this quality assurance initiative, we sought to determine whether racial disparities exist in ACP at our institution.
METHODS: We performed a retrospective chart review of patients 65 years of age and older who were seen at our institution from 1/1/2021 through 12/31/2022. The primary objective was to determine whether racial disparities exist in ACP among these patients. ACP were identified if the electronic health record indicated presence of an advance directive, health care power of attorney, and/or ACP discussion or visit with a clinician.
RESULTS: 22,372 patients were included. The median age was 74.1 (interquartile range [IQR] 69.4 - 80.5). 87.4% of patients were White, 11.2% were Black, and 1.4% were another race. 51.5% were female, 55.1% were married, and 88 % were insured by Medicare. Black patients and patients of other races were less likely than White patients to have an ACP (adjusted odds ratio [aOR] = 0.64; 95% confidence interval [CI], 0.58-0.71; P <.0001 and aOR = 0.63; 95% CI, 0.48- 0.82; P = .0007, respectively). Older patients and those with more chronic disease (elevated Charlson comorbidity index) were more likely to complete ACP (aOR = 1.48; 95% CI, 1.42-1.54; P < .0001 and aOR = 1.32; 95% CI, 1.30-1.35; P < .0001, respectively).
CONCLUSIONS: Our findings show differences in rates of ACP completion by race at our institution, which is consistent with previous research. The next step in our quality initiative is to develop interventions to promote equitable opportunities for such planning.