Disparities in Care Management During Terminal Hospitalization Among Adults With Metastatic Cancer From 2010 to 2017

Abstract

Key Points Question Is variation in care management during terminal hospitalization among adults with metastatic cancer associated with sociodemographic status? Findings In this cross-sectional study of 21 335 patients with metastatic cancer who died in the hospital, racial and ethnic minority patients and those with Medicare or Medicaid coverage were more likely to receive low-value, high-cost aggressive medical interventions at the end of life. Meaning This study’s findings suggest that identifying and understanding factors associated with the observed disparities will be helpful to inform communications with patients with metastatic cancer about end-of-life care.

Navigating the Complex Ecosystem of Race, Ethnicity, Structural Racism, Socioeconomic Factors, Medical Care Delivery, and End-of-Life Care—Casting Away the Compass to Make a Map

“…The authors’ findings support those of previous studies in which minority race or ethnicity and lower socioeconomic status have been associated with higher rates of aggressive end-of-life interventions. Although these data highlight potential structural racism within the medical care system and beneficially illuminate the importance of studying associations between outcomes, race, ethnicity, and socioeconomic factors, they offer a limited view of a much more complex and nuanced ecosystem.…”

“…Deeb et al present the results of an epidemiologic study assessing data from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project national inpatient sample in the US from 2010 to 2017. The team created a database of patients with metastatic cancer who were hospitalized and died during the hospitalization (defined as a terminal hospitalization) and explored potential associations between aggressive end-of-life treatments and patient ethnicity, race, socioeconomic status, payer type, age, hospital type (teaching vs nonteaching), and geographic region.…”

Racial differences in low value care among older adult Medicare patients in US health systems: retrospective cohort study

“…At an interpersonal level, clinicians’ implicit or explicit biases51 and patient-clinician racial discordance5253 might contribute to clinician misperceptions of patient needs, less effective communication, and in turn, greater clinical uncertainty54 that prompts more testing 555657. In a similar vein, we found Black patients with advanced dementia were more likely to receive feeding tubes, mirroring evidence that patients from racial and ethnic minority groups were more likely to receive high cost, aggressive interventions at the end of life 255859. These findings may be due to patients in racial and ethnic minority groups having fewer treatment limitations in place (eg, do not resuscitate orders), more severe illness, or different end-of-life preferences 5758.…”

“… 55 56 57 In a similar vein, we found Black patients with advanced dementia were more likely to receive feeding tubes, mirroring evidence that patients from racial and ethnic minority groups were more likely to receive high cost, aggressive interventions at the end of life. 25 58 59 These findings may be due to patients in racial and ethnic minority groups having fewer treatment limitations in place (eg, do not resuscitate orders), more severe illness, or different end-of-life preferences. 57 58 At a structural level, these results might reflect decades of structural racism resulting in racially segregated neighborhoods and lower density of primary care clinics and high quality urgent care centers 60 in predominantly Black neighborhoods compared with White neighborhoods.…”

Evaluation of Direct Medical Costs and Associated Factors Within the Last 30 days of Life of Hospitalized Cancer Patients

“…Identifying patients with a high probability of receiving aggressive measures which worsen the quality of life in the terminal process is of fundamental importance to improving palliative patient care. 33 Discussions about end-of-life care should be started systematically and early to enable patients to make more conscious and informed choices about their health condition, obtain better control and relief of symptoms and opportunities to solve family and personal problems. [34][35][36][37] Establishing advance directives, limiting obstinate and futile therapeutic interventions, supported by a decision shared with the care team, was a variable associated with the introduction of palliative care in end-of-life care, promoting respect for the individual's wishes and offering care adequate to the health needs of patients in an advanced stage of the disease, with an impact on care costs.…”