Low-Value End-of-Life Care in Some Patients With Cancer

Patients with metastatic cancer are more likely to receive low-value, aggressive interventions at the end of life if they belong to racial and ethnic minority groups or have Medicare or Medicaid coverage, according to new findings.

Black patients and those covered by public insurance were more likely to be admitted from the emergency department (ED) and also of being placed on a ventilator. They were also more likely to incur higher total charges. Similar trends were observed among patients of Asian and Hispanic ethnicity.

Patients who were hospitalized at urban academic centers were more likely to receive systemic therapy and ventilation and to incur higher total costs.

“In the study, we identified several groups at higher risk of receiving higher-cost and low-value interventions at the end of life,” said study author Stephanie Deeb, a medical student at the Icahn School of Medicine at Mount Sinai, in New York City. “The factors that contribute to these disparities are complex and encompass possible communication barriers and barriers in access to care.

“However, these findings also highlight opportunities to promote high-value care at the end of life by improving communication and addressing possible structural biases,” she added.

Deeb presented the study results at the American Society of Clinical Oncology (ASCO) 2021 annual meeting, which was held virtually because of the pandemic.

In a discussion of the paper, Maxwell Thomas Vergo, MD, from the Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, said that the findings of this study are important for several reasons. One is that 10% to 30% of patients with metastatic disease die in the hospital, and hospital death can have a bearing on caregiver bereavement. “Most studies look at end-of-life care in the last 30 days of life, but they don’t really include what the last days or hours of life look like, which can be tremendously important,” he said.

“Strengths of this study were that it was generalizable, given the diversity of geography, race/ethnicity, payer, and hospital type,” said Vergo. “The use of multiple regression analysis helps minimize unmeasured confounders, and it’s another example of using a large dataset to answer a clinical question.”

Disparities Prevalent in End-of-Life Care

Racial disparities in cancer outcomes remain a challenge. Some research suggests that these differences may be due more to socioeconomic factors than race. For patients with prostate cancer, for example, there was no difference in prostate cancer–specific mortality rates between Black and White patients when they all had equal access to care, as previously reported by Medscape Medical News.

In her presentation, Deeb noted that previous research has demonstrated that there are racial disparities in end-of-life cancer care. Among patients of certain minority racial and ethnic groups, these disparities included higher odds of aggressive care, more prolonged hospitalizations, and higher odds of dying in the hospital.

Deeb pointed out that “no prior study has specifically examined in-patient deaths among patients with metastatic cancer on a population level in the US.” That is what her team set out to do.

They conducted a retrospective population-based cohort analysis of encounter-level data using the National Inpatient Sample, which included records from 2010–2017 for patients aged 18 years and older who had metastatic cancer and who died during hospitalization.

They identified 321,898 hospitalizations among patients with metastatic cancer; of those patients, 21,335 (6.6%) were terminally ill. The majority of patients were White (65.9%); 14.1% were Black; and 7.5% were Hispanic. Just over half of the cohort (58.2%) were insured by Medicare or Medicaid; 33.2% were privately insured.

Overall, 63.2% of patients were admitted from the ED, 4.6% received systemic therapy, and 19.2% received invasive ventilation. Median total charges were $43,681.

As compared with White patients, Black patients were more likely to be admitted from the ED (odds ratio [OR], 1.39; P < .0001), as were Hispanic patients (OR, 1.45; P < .0001) and Asian or Pacific Islanders (OR, 1.43; P < .0001).

Similar trends were seen for receipt of systemic therapy (OR, 0.78; P = .020; 0.97; P = 0.77; OR, 0.92; P = .66), and invasive ventilation (OR, 1.59; P < .0001; OR, 1.14; P = .063; OR, 1.20; P = .073, respectively).

“Among Black non-Hispanic patients, we saw higher odds of ED admission, lower odds of receiving systemic therapy, higher odds of invasive ventilation, longer hospitalizations, and higher total charges,” said Deeb. “Among Hispanic patients, we saw higher odds of ED admission and higher total charges. Among Asian and Pacific Islander patients, we observed higher odds of ED admission, longer hospitalizations, and greater total charges.”

There was higher utilization of high-cost and low-value end-of-life care among minority patients and those with Medicare and Medicaid insurance, she pointed out. “In prior studies, there have been lower rates of hospice enrollment reported among Black, Asian, and Hispanic patients with advanced cancer,” said Deeb. “We weren’t able to directly measure hospice enrollment in our cohort, but these lower rates of hospice enrollment have been correlated with higher rates of aggressive care, similar to the ones that we observed in this study.”

Understanding Mechanism of Disparities

As well as pointing out the strengths of the study, discussant Vergo highlighted some limitations of this research, one being that the primary cancer diagnosis was not included. “Having that information could help to understand these data,” he pointed out.

Another limitation is that there were unmeasured confounders. “We don’t know what the patient values and goals were in this study and if those were associated with any of the covariates,” he said. “This was a great study to understand the disparities, but to understand the mechanisms of those disparities is going to be particularly important going forward.”

The take-away from the study is that disparities in end-of-life care exist during a hospitalization. “But without mechanisms of action, it may be challenging to pick an intervention that would target these disparities,” Vergo said.

The study was funded by the US National Institutes of Health and the Icahn School of Medicine at Mount Sinai. Deeb and Vergo have disclosed no relevant financial relationships.

American Society of Clinical Oncology (ASCO) 2021: Abstract 12008. Presented June 5, 2021

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