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Table 1 shows the results of our post hoc analysis assessing the 202 African-American and white patients in our trial. African-Americans were significantly younger, had similar comorbidities (data not shown), but were less likely to have advance directives documented or resuscitation status documented prior to generating an EWS alert during their hospital stay. A first request for advance directives, documentation of resuscitation status prior to hospital discharge, a documented change in resuscitation status, and delivery of a formal palliative care consultation was similar for both races. However, having documented advance directives prior to hospital discharge was significantly less common among African-American patients. We also found that hospital mortality and ICU transfer were significantly greater for white patients, whereas hospital length of stay was less for African-American patients. One of the limitations of our study is that severity of illness may not have been adequately characterized (we employed age and comorbidities), which may have accounted for some of the outcome differences observed.
In summary, our post hoc analysis would suggest that racial differences in documentation of advance directives can vary by race among hospitalized patients generating an EWS alert, with most of this disparity being present prior to generation of the EWS alert. Furthermore, the delivery of specific interventions linked to palliative care (request for first-time advance directives, formal palliative care consultation, and change in resuscitation status) did not vary by race. The impact of socioeconomic factors on palliative care for hospitalized patients seems to be complex and dependent on many factors. We agree with Drs. Huber and Edelson (4) that more research is needed to determine if automated systems can overcome these factors in order to provide more uniform palliative care to those who might benefit from it (5).