Use of aggressive, costly end-of-life cancer treatment varies by race, insurance status
An analysis of patients with metastatic cancer revealed higher use of low-value, aggressive and more costly end-of-life interventions for those who belonged to racial or ethnic minority groups, according to retrospective study results.
The findings — presented during the virtual ASCO Annual Meeting — also showed higher use of these interventions for Medicare or Medicaid recipients.
“It is important to consider health care disparities based on race/ethnicity and insurance status in all areas of medical care, including end-of-life medical management,” researcher C. Jillian Tsai, MD, PhD, radiation oncologist in the department of radiation oncology at Memorial Sloan Kettering Cancer Center, told Healio. “It is important to consider factors that may be contributing to these trends and employ practices that can improve communication and encourage early advanced care planning for patients with advanced disease.”
Patients with metastatic cancer often receive high-cost, low-value care near the end of life.
“Prior studies have highlighted associations between aggressive end-of-life care and poorer patient quality of life, psychological distress among caregivers and family members, and greater costs of care at the end of life,” researcher Stephanie Deeb, BS, third-year medical student at Icahn School of Medicine at Mount Sinai, told Healio.
Investigators retrospectively analyzed interventions performed during terminal hospitalizations to determine which patients with metastatic cancer were most likely to receive what they called “futile care.”
“Terminal illness is a source of physical, emotional and financial strain for patients and their families,” Deeb said. “Aggressive end-of-life care can contribute to this burden, and we were interested in analyzing recent patterns in the use of aggressive medical interventions among patients with terminal cancer to identify potential areas to improve care at the end of life.”
Researchers performed a population-based cohort analysis of encounter-level data from the National Inpatient Sample. The analysis — which included records from 2010 to 2017 — focused on patients aged 18 years or older with metastatic cancer who died while hospitalized.
Investigators utilized multivariable binomial logistic regression models to evaluate associations between exposures — including patient demographics — and receipt of aggressive, high-cost and low-value medical care.
Deeb, Tsai and colleagues identified 321,898 hospitalizations among patients with metastatic cancer.
They determined 21,335 (6.6%) had terminal cancer; two-thirds (65.9%) of these patients were white, 14.1% were Black and 7.5% were Hispanic. More than half (58.2%) had Medicare or Medicaid, whereas 33.2% had private insurance.
The majority (63.2%) were admitted from the ED, 4.6% received systemic therapy and 19.2% received invasive ventilation.
Researchers reported median total charges of $43,681.
Admission from the ED occurred significantly more frequently among Black (OR = 1.39; 95% CI, 1.27-1.52), Hispanic (OR = 1.45; 95% CI, 1.28-1.64) and Asian/Pacific Islander (OR = 1.43; 95% CI, 1.2-1.72) patients than non-Hispanic white patients.
Black patients also were significantly more likely than non-Hispanic white patients to receive invasive ventilation (OR = 1.59; 95% CI, 1.44-1.75). Researchers reported similar trends among Hispanic and Asian/Pacific Islander patients; however, those differences did not reach statistical significance.
Patients from racial or ethnic minority groups appeared significantly more likely than non-Hispanic white patients to have total charges significantly higher than the median for the overall cohort (Black, OR = 1.23; 95% CI, 1.13-1.34; Hispanic, OR = 1.5; 95% CI, 1.34-1.69; Asian/Pacific Islander, OR = 1.35; 95% CI, 1.13-1.6).
Insurance type, as well as hospital location and type, also appeared associated with end-of-life care.
Patients with private insurance appeared significantly less likely than those with public insurance to be admitted from the ED (OR = 0.47; 95% CI, 0.44-0.51), receive invasive ventilation (OR = 0.75; 95% CI, 0.69-0.82) and have total charges higher than the median for the overall cohort (OR = 0.64; 95% CI, 0.59-0.68).
Compared with patients treated at rural hospitals, those treated at urban or teaching hospitals were significantly more likely to receive systemic therapy (OR = 2.79; 95% CI, 1.84-4.24) and invasive ventilation (OR = 2.91; 95% CI, 2.4-3.54). Patients treated at urban or teaching hospitals also were more likely to have total charges higher than the median for the overall cohort (OR = 3.81; 95% CI, 3.34-4.35).
“Our findings aligned with prior work that highlighted racial/ethnic disparities in end-of-life care, and demonstrated these trends in a large national cohort of patients with metastatic disease,” Tsai said. “It is disappointing to note these disparities, but identifying these trends is an important step in addressing them and advancing appropriate and equitable care at the end of life.”
Additional studies are necessary to determine the underlying causes of the disparities, according to the researchers.
“Communication barriers appear to be a major factor contributing to these trends,” Tsai told Healio. “This encompasses personal and cultural preferences for medical care that vary widely among patients and can impact decisions regarding end-of-life care, as well as language barriers and the effective use of professional interpreters. However, we hope to pursue qualitative work evaluating patient views on end-of-life care and advanced care planning to provide deeper insight into the factors underlying these trends.”
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Deeb S, et al. Abstract 12008. Presented at: ASCO Annual Meeting (virtual meeting); June 4-8, 2021.