End‐of‐life quality metrics among medicare decedents at minority‐serving cancer centers: A retrospective study

Abstract

Background We calculated the performance of National Cancer Institute (NCI)/National Comprehensive Cancer Network (NCCN) cancer centers’ end‐of‐life (EOL) quality metrics among minority and white decedents to explore center‐attributable sources of EOL disparities. Methods We conducted a retrospective cohort study of Medicare beneficiaries with poor‐prognosis cancers who died between April 1, 2016 and December 31, 2016 and had any inpatient services in the last 6 months of life. We attributed patients’ EOL treatment to the center at which they received the preponderance of EOL inpatient services and calculated eight risk‐adjusted metrics of EOL quality (hospice admission ≤3 days before death; chemotherapy last 14 days of life; ≥2 emergency department (ED) visits; intensive care unit (ICU) admission; or life‐sustaining treatment last 30 days; hospice referral; palliative care; advance care planning last 6 months). We compared performance between patients across and within centers. Results Among 126,434 patients, 10,119 received treatment at one of 54 NCI/NCCN centers. In aggregate, performance was worse among minorities for ED visits (10.3% vs 7.4%, P < .01), ICU admissions (32.9% vs 30.4%, P = .03), no hospice referral (39.5% vs 37.0%, P = .03), and life‐sustaining treatment (19.4% vs 16.2%, P < .01). Despite high within‐center correlation for minority and white metrics (0.61‐0.79; P < .01), five metrics demonstrated worse performance as the concentration of minorities increased: ED visits (P = .03), ICU admission (P < .01), no hospice referral (P < .01), and life‐sustaining treatments (P < .01). Conclusion EOL quality metrics vary across NCI/NCCN centers. Within center, care was similar for minority and white patients. Minority‐serving centers had worse performance on many metrics.

Greater preferences for death in hospital and mechanical ventilation at the end of life among non-whites recently diagnosed with cancer

“…A recently published analysis of over 125,000 Medicare bene ciaries treated at NCI/NCCN cancer centers showing that minority-serving cancer centers independently had inferior performance on EOL quality metrics translating to more aggressive EOL measures including ICU admissions and lack of hospice referral. 1 Place of death may serve as a surrogate for aggressiveness of care as death within a hospital can correspond with decreased participation in hospice services. Data reveal that a majority (50-90%) of cancer patients express a preference for dying at home.…”

“…Previous studies have shown that racial/ethnic minority cancer patients disparately receive more aggressive end-of-life (EOL) care de ned as admission to higher acuity care in their nal days, lack of hospice utilization, and use of mechanical ventilation. [1][2][3] Not only are these aggressive measures indicative of potentially lower quality EOL care, 4,5 but they also raise the question of whether racial and ethnic minorities are experiencing what the Institute of Medicine (IOM) terms "a good death". 6 Furthermore, overly aggressive end-of-life (EOL) measures can result in elevated health care costs, negatively impact patients' quality of life and have detrimental effects on patients loved ones.…”

“…5,12 Findings that minority cancer patients receive more aggressive care at the EOL raise the question of whether lack of access to effective palliative care and hospice programs is at fault. 1 However, a recent population based study among cancer patients in Texas examined racial differences in hospice use with payer characteristics and found that even as hospice enrollment differences were eliminated between feefor-service and managed care Medicare bene ciaries due to increased access to hospice bene ts, racial/ethnic disparities in hospice enrollment persisted. 13 This raised the question of whether preferences for more aggressive care were contributing to observed EOL care disparities.…”

Role of norms in variation in cancer centers’ end-of-life quality: qualitative case study protocol

“…We chose a qualitative case study design at six sites to identify local organizational and provider practice norms that influence variation in EOL treatment intensity, particularly for minority patients. Based on 2016 Medicare claims data analyses, [26] we will recruit 6 of the 11 NCI/NCCN designated cancer centers serving at least 15% African American advanced cancer patients. We based our sample size on recent literature related to sample size sufficiency, recommendations to reach multi-site data saturation, and qualitative research expertise of our study team.…”

“…We measured EOL care intensity based upon risk-adjusted metrics of EOL quality using 2016 Medicare fee-for-service claims data: receipt of chemotherapy in the last 14 days of life (NQF #0210), intensive care unit (ICU) admission in the last 30 days of life (NQF #0213), and non (NQF #0215) or late (NQF #0216) hospice referral. Our approach to calculating these EOL quality metrics has been published elsewhere [ 26 ]. Given the multivariable nature of these metrics, we use data visualization to purposively select sites for case study that maximize potential heterogeneity in practice patterns [ 34 ].…”