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

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.
Importance Many patients with metastatic cancer receive high-cost, low-value care near the end of life. Identifying patients with a high likelihood of receiving low-value care is an important step to improve appropriate end-of-life care. Objective To analyze patterns of care and interventions during terminal hospitalizations and examine whether care management is associated with sociodemographic status among adult patients with metastatic cancer at the end of life. Design, Setting, and Participants This retrospective, population-based cross-sectional study used data from the Healthcare Cost and Utilization Project to analyze all-payer, encounter-level information from multiple inpatient centers in the US. All utilization and hospital charge records from national inpatient sample data sets between January 1, 2010, and December 31, 2017 (n = 58 761 097), were screened. The final cohort included 21 335 patients 18 years and older at inpatient admission who had a principal diagnosis of metastatic cancer and died during hospitalization. Data for the current study were analyzed from January 1, 2010, to December 31, 2017. Exposures Patient demographic characteristics, patient insurance status, hospital location, and hospital teaching status. Main Outcomes and Measures Receipt of systemic therapy (including chemotherapy and immunotherapy), receipt of invasive mechanical ventilation, emergency department (ED) admission, time from hospital admission to death, and total charges during a terminal hospitalization. Results Among 21 335 patients with metastatic cancer who had terminal hospitalizations between 2010 and 2017, the median age was 65 years (interquartile range, 56-75 years); 54.0% of patients were female; 0.5% were American Indian, 3.3% were Asian or Pacific Islander, 14.1% were Black, 7.5% were Hispanic, 65.9% were White, and 3.1% were identified as other; 58.2% were insured by Medicare or Medicaid, and 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 mechanical ventilation during hospitalization. Racial and ethnic minority patients had a higher likelihood of being admitted from the ED (Asian or Pacific Islander patients: odds ratio [OR], 1.43 [95% CI, 1.20-1.72]; P
This cross-sectional study uses data from the Healthcare Cost and Utilization Project national inpatient sample between 2010 and 2017 to examine care management patterns during terminal hospitalization among adult patients with metastatic cancer.