scholarly journals Racial Disparities in Health Care Utilization at the End of Life Among New Jersey Medicaid Beneficiaries With Advanced Cancer

2020 ◽  
Vol 16 (6) ◽  
pp. e538-e548 ◽  
Author(s):  
Annie Yang ◽  
David Goldin ◽  
Jose Nova ◽  
Jyoti Malhotra ◽  
Joel C. Cantor ◽  
...  
Keyword(s):  
New Jersey ◽  
End Of Life ◽  
Advanced Cancer ◽  
Ethnic Disparities ◽  
Racial And Ethnic Disparities ◽  
Data Set ◽  
Icu Admission ◽  
Black Patients ◽  
Medicaid Beneficiaries ◽  
Eol Care

PURPOSE: Racial and ethnic disparities in cancer care near the end of life (EOL) have been recognized, but EOL care experienced by Medicaid beneficiaries is not well understood. We assessed the prevalence of aggressive EOL care and hospice enrollment for Medicaid beneficiaries and determined whether racial and ethnic disparities exist. PATIENTS AND METHODS: We identified Medicaid beneficiaries (age 21-64 years) who were diagnosed from 2011 to 2015 with stage IV breast and colorectal cancer and who died by January 2016 through a New Jersey State Cancer Registry–Medicaid claims linked data set. We measured aggressive EOL care (> 1 hospitalization, > 1 emergency department [ED] visit, any intensive care unit [ICU] admission in the last 30 days of life, and receipt of chemotherapy in the last 14 days of life) and hospice enrollment. Multivariable logistic regression models were used to determine factors associated with aggressive EOL care and hospice enrollment. RESULTS: Of the 349 patients, 217 (62%) received at least one of the following measures of aggressive EOL care: > 1 hospitalization (27%), > 1 ED visit (31%), ICU admission (30%), and chemotherapy (34%). The adjusted odds of receiving any aggressive care were 1.87 times higher (95% CI, 1.08 to 3.26) for non-Hispanic (NH) Black patients compared with NH White patients. Only 39% of patients enrolled in hospice. No significant differences in hospice enrollment were observed by race or ethnicity. CONCLUSION: The majority of Medicaid patients with advanced cancer received aggressive EOL care and were not enrolled in hospice. NH Black patients were more likely to receive aggressive EOL care. Further work to understand processes leading to suboptimal EOL care within Medicaid populations and among racial and ethnic minority groups is warranted.

scholarly journals Racial Differences in Predictors of Intensive End-of-Life Care in Patients With Advanced Cancer

2009 ◽  
Vol 27 (33) ◽  
pp. 5559-5564 ◽  
Author(s):  
Elizabeth Trice Loggers ◽  
Paul K. Maciejewski ◽  
Elizabeth Paulk ◽  
Susan DeSanto-Madeya ◽  
Matthew Nilsson ◽  
...  
Keyword(s):  
End Of Life ◽  
Racial Differences ◽  
Advanced Cancer ◽  
Do Not Resuscitate ◽  
Advanced Cancer Patients ◽  
Black Patients ◽  
Patient Reported ◽  
Eol Care ◽  
To Receive ◽  
White Patients

Purpose Black patients are more likely than white patients to receive life-prolonging care near death. This study examined predictors of intensive end-of-life (EOL) care for black and white advanced cancer patients. Patients and Methods Three hundred two self-reported black (n = 68) and white (n = 234) patients with stage IV cancer and caregivers participated in a US multisite, prospective, interview-based cohort study from September 2002 to August 2008. Participants were observed until death, a median of 116 days from baseline. Patient-reported baseline predictors included EOL care preference, physician trust, EOL discussion, completion of a Do Not Resuscitate (DNR) order, and religious coping. Caregiver postmortem interviews provided information regarding EOL care received. Intensive EOL care was defined as resuscitation and/or ventilation followed by death in an intensive care unit. Results Although black patients were three times more likely than white patients to receive intensive EOL care (adjusted odds ratio [aOR] = 3.04, P = .037), white patients with a preference for this care were approximately three times more likely to receive it (aOR = 13.20, P = .008) than black patients with the same preference (aOR = 4.46, P = .058). White patients who reported an EOL discussion or DNR order did not receive intensive EOL care; similar reports were not protective for black patients (aOR = 0.53, P = .460; and aOR = 0.65, P = .618, respectively). Conclusion White patients with advanced cancer are more likely than black patients with advanced cancer to receive the EOL care they initially prefer. EOL discussions and DNR orders are not associated with care for black patients, highlighting a need to improve communication between black patients and their clinicians.

Personalized end-of-life care: Associations between patient preferences and treatment intensity near death

2009 ◽  
Vol 27 (15_suppl) ◽  
pp. 6516-6516 ◽  
Author(s):  
A. A. Wright ◽  
J. W. Mack ◽  
E. D. Trice ◽  
T. A. Balboni ◽  
S. D. Block ◽  
...  
Keyword(s):  
Medical Care ◽  
End Of Life ◽  
Advanced Cancer ◽  
Treatment Center ◽  
Treatment Intensity ◽  
Cancer Type ◽  
Do Not Resuscitate ◽  
Icu Admission ◽  
Eol Care ◽  
Prospective Longitudinal

6516 Background: Medical treatment at the end-of-life (EOL) should be responsive to patient values, but research shows it may instead reflect the regional supply of health services and/or physician practice patterns. We sought to determine whether patients' preferences are associated with EOL medical care and place of death. Methods: Coping with Cancer is an NCI/NIMH-funded, multi-site prospective, longitudinal cohort study of patients with advanced cancer, conducted from September 2002-February 2008. Analyses were based upon 317 deceased patients interviewed at baseline and followed until death, a median of 4.4 months later. EOL care was obtained from chart review, and regressed on patients' baseline preferences for life-extending therapy. Analyses were adjusted for significant confounds; i.e., socio-demographics, cancer type, patient denial, EOL discussion, do-not resuscitate (DNR) order, and treatment center. A sub-analysis examined EOL care within three different medical centers to determine whether patients' preferences and treatment intensity varied by region/practice type. Results: 90 of 317 patients (28.4%) reported a desire to receive life-extending therapy at baseline. Patients' preferences did not differ by proximity to death or performance status, but patients who preferred life-extending therapy had higher rates of denial (75.0% vs. 55.6%, p = 0.002) and were less likely to report having an EOL conversation (24.4% vs. 48.9%, p = 0.0002) or a DNR order (24.4% vs. 48.9%, p < 0.0001). These patients were more likely to undergo ICU admission (AOR 4.6, 95% CI 1.9–11.1) and ventilation (AOR 3.0, 95% CI 1.2–7.3), and die in an ICU (AOR 6.7, 95% CI 2.4–18.7) instead of at home (AOR 0.6, 95% CI 0.3–0.9). A sub-analysis of patients treated at Yale, Parkland, and New Hampshire Oncology-Hematology confirmed that patients' preference for life-extending treatment was associated with higher rates of ICU admission in all three centers. Conclusions: Advanced cancer patients' treatment preferences may play a more important role in determining the intensity of medical care at the EOL than previously recognized. Future research should determine whether these preferences are informed and thus reflect patients' true values for EOL care. No significant financial relationships to disclose.

scholarly journals The Mediation Effects of Perceived Healthcare Discrimination on Racial and Ethnic Disparities in End of Life Care

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 963-963
Author(s):  
Junghee Han
Keyword(s):  
End Of Life ◽  
Race And Ethnicity ◽  
Ethnic Disparities ◽  
Mediating Effect ◽  
Place Of Death ◽  
Racial And Ethnic Disparities ◽  
Mediating Effects ◽  
Mediation Effects ◽  
Hospice Use ◽  
Eol Care

Abstract Numerous studies demonstrate racial and ethnic differences in end-of-life (EOL) care, including place of death and hospice use. Experiencing discrimination in healthcare is often cited in the literature as a potent source explaining the pathways of the racial and ethnic disparities in EOL care. However, none of the studies have tested its mediating effects on racial and ethnic disparities in EOL care. The study examines if the effects of race and ethnicity on place of death and hospice use are mediated by perceived healthcare discrimination. This is a secondary analysis of 2008-2014 data from the nationally representative Health and Retirement Study, including oversampling of Blacks and Hispanics. Samples included 1,446 decedents aged 65 or older who completed an exit interview by proxy. Perceived healthcare discrimination was measured by a self-report of receiving poorer service or treatment than other people from doctors or hospitals. In multivariate analyses, Blacks were more likely to die at hospitals (OR=1.57, p &lt; .05) than Whites. Those who experienced discriminatory healthcare were more likely to die at hospitals than those who never experienced discriminatory healthcare (OR=1.44, p &lt; .05). However, the Karlson-Home-Breen (KHB) method showed no significant mediating effects of perceived healthcare discrimination on racial and ethnic disparities in place of death. Race and ethnicity did not affect hospice use. Although there is no mediating effect of healthcare discrimination on racial and ethnic disparities in EOL care, its direct impact is observed. The research contributes to evidence on the significant role of discrimination in healthcare choices.

scholarly journals End-of-Life Racial and Ethnic Disparities Among Patients With Ovarian Cancer

2017 ◽  
Vol 35 (16) ◽  
pp. 1829-1835 ◽  
Author(s):  
Jolyn S. Taylor ◽  
Suja S. Rajan ◽  
Ning Zhang ◽  
Larissa A. Meyer ◽  
Lois M. Ramondetta ◽  
...  
Keyword(s):  
Ovarian Cancer ◽  
Hospital Admission ◽  
End Of Life ◽  
End Of Life Care ◽  
Ethnic Disparities ◽  
Life Care ◽  
Icu Admission ◽  
Medicare Data ◽  
Black Patients ◽  
Hispanic Patients

Purpose To assess disparities in end-of-life care among patients with ovarian cancer. Patients and Methods Using Texas Cancer Registry-Medicare data, we assessed patients with ovarian cancer deceased in 2000 to 2012 with at least 13 months of continuous Medicare coverage before death. Descriptive statistics and multivariate logistic regressions were conducted to evaluate end-of-life care, including chemotherapy in the final 14 days of life, intensive care unit (ICU) admission in the final 30 days of life, more than one emergency room (ER) or hospital admission in the final 30 days of life, invasive or life-extending procedures in the final 30 days of life, enrollment in hospice, enrollment in hospice during the final 3 days of life, and enrollment in hospice while not hospitalized. Results A total of 3,666 patients were assessed: 2,819 (77%) were white, 553 (15%) Hispanic, 256 (7%) black, and 38 (1%) other. A total of 2,642 (72%) enrolled in hospice before death, but only 2,344 (64%) died while enrolled. The median hospice enrollment duration was 20 days. In the final 30 days of life, 381 (10%) had more than one ER visit, 505 (14%) more than one hospital admission, 593 (16%) ICU admission, 848 (23%) invasive care, and 418 (11%) life-extending care. In the final 14 days of life, 357 (10%) received chemotherapy. Several outcomes differed for minorities compared with white patients. Hispanic and black patients were less likely to enroll and die in hospice (black odds ratio [OR], 0.66; 95% CI, 0.50 to 0.88; P = .004; Hispanic OR, 0.76; 95% CI, 0.61 to 0.94; P = .01). Hispanic patients were more likely to be admitted to an ICU (OR, 1.37; 95% CI, 1.05 to 1.78; P = .02), and black patients were more likely to have more than one ER visit (OR, 2.20; 95% CI, 1.53 to 3.16; P < .001) and receive a life-extending procedure (OR, 2.13; 95% CI, 1.49 to 3.04; P < .001). Conclusion We found being a minority was associated with receiving intensive and invasive end-of-life care among patients with ovarian cancer.

Racial and Ethnic Disparities in Adverse Perinatal Outcomes at Term

2021 ◽  
Author(s):  
Jacqueline G. Parchem ◽  
Madeline Murguia Rice ◽  
William A. Grobman ◽  
Jennifer L. Bailit ◽  
Ronald J. Wapner ◽  
...  
Keyword(s):  
Relative Risk ◽  
Primary Outcome ◽  
Perinatal Death ◽  
Ethnic Disparities ◽  
Perinatal Outcomes ◽  
Adjusted Relative Risk ◽  
Racial And Ethnic Disparities ◽  
Risk Pregnancy ◽  
Black Patients ◽  
Adverse Perinatal Outcomes

Objective This study aimed to evaluate whether racial and ethnic disparities in adverse perinatal outcomes exist at term. Study Design We performed a secondary analysis of a multicenter observational study of 115,502 pregnant patients and their neonates (2008–2011). Singleton, nonanomalous pregnancies delivered from 37 to 41 weeks were included. Race and ethnicity were abstracted from the medical record and categorized as non-Hispanic White (White; referent), non-Hispanic Black (Black), non-Hispanic Asian (Asian), or Hispanic. The primary outcome was an adverse perinatal composite defined as perinatal death, Apgar score < 4 at 5 minutes, ventilator support, hypoxic–ischemic encephalopathy, subgaleal hemorrhage, skeletal fracture, infant stay greater than maternal stay (by ≥ 3 days), brachial plexus palsy, or facial nerve palsy. Results Of the 72,117 patients included, 48% were White, 20% Black, 5% Asian, and 26% Hispanic. The unadjusted risk of the primary outcome was highest for neonates of Black patients (3.1%, unadjusted relative risk [uRR] = 1.16, 95% confidence interval [CI]: 1.04–1.30), lowest for neonates of Hispanic patients (2.1%, uRR = 0.80, 95% CI: 0.71–0.89), and no different for neonates of Asian (2.6%), compared with those of White patients (2.7%). In the adjusted model including age, body mass index (BMI), smoking, obstetric history, and high-risk pregnancy, differences in risk for the primary outcome were no longer observed for neonates of Black (adjusted relative risk [aRR] = 1.06, 95% CI: 0.94–1.19) and Hispanic (aRR = 0.92, 95% CI: 0.81–1.04) patients. Adding insurance to the model lowered the risk for both groups (aRR = 0.85, 95% CI: 0.75–0.96 for Black; aRR = 0.68, 95% CI: 0.59–0.78 for Hispanic). Conclusion Although neonates of Black patients have the highest frequency of adverse perinatal outcomes at term, after adjustment for sociodemographic factors, this higher risk is no longer observed, suggesting the importance of developing strategies that address social determinants of health to lessen extant health disparities. Key Points

Racial and ethnic disparities in the provision of epidural analgesia to Georgia Medicaid beneficiaries during labor and delivery

2004 ◽  
Vol 191 (2) ◽  
pp. 456-462 ◽  
Author(s):  
George Rust ◽  
Wendy N. Nembhard ◽  
Michelle Nichols ◽  
Folashade Omole ◽  
Patrick Minor ◽  
...  
Keyword(s):  
Epidural Analgesia ◽  
Ethnic Disparities ◽  
Labor And Delivery ◽  
Racial And Ethnic Disparities ◽  
Medicaid Beneficiaries

scholarly journals Racial and Ethnic Disparities in Palliative Care: A Systematic Scoping Review

2018 ◽  
Vol 99 (4) ◽  
pp. 301-316 ◽  
Author(s):  
Daniel S. Gardner ◽  
Meredith Doherty ◽  
Gleneara Bates ◽  
Aliza Koplow ◽  
Sarah Johnson
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Scoping Review ◽  
End Of Life Care ◽  
Ethnic Disparities ◽  
Racial And Ethnic Disparities ◽  
Life Care ◽  
Search Terms ◽  
Communities Of Color ◽  
Social Environmental

Despite the advances and spread of palliative care programs, communities of color remain significantly underserved. Although these disparities are widely known, there is a marked lack of empirical evidence. The authors conducted a systematic scoping review that synthesized the literature since 2000 about racial and ethnic disparities in palliative and end-of-life care. We searched PubMed, Medline, SocIndex, CINAHL, Social Work Abstracts, and PsycINFO, using search terms including palliative care or end-of-life care, disparities or barriers or utilization, and race or ethnicity or African American or Hispanic. Findings lend support to extant literature that social-environmental barriers and disparities distinctly affect access to care for these populations. The review expands upon understanding of how social determinants drive disparities in palliative and end-of-life care and suggests implications for practice, policy, and research in promoting health equity in serious illness.

Quality of End-of-Life Care for the Myelodysplastic Syndromes: Findings from a Large National Database

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 3287-3287
Author(s):  
Sean A. Fletcher ◽  
Angel M. Cronin ◽  
Amer M. Zeidan ◽  
Oreofe O. Odejide ◽  
Steven D. Gore ◽  
...  
Keyword(s):  
Marital Status ◽  
End Of Life ◽  
Solid Tumors ◽  
Myelodysplastic Syndromes ◽  
Research Funding ◽  
National Database ◽  
Icu Admission ◽  
Eol Care ◽  
Over Time

Abstract Background: End-of-life (EOL) care has been shown to be more intensive for blood cancers compared to solid tumors (e.g. Hui, Cancer, 2014); however, data are sparse regarding predictors of intensive care unit (ICU) use in the last 30 days of life and hospice enrollment among patients with specific hematologic malignancies. Moreover, little is known about EOL care specifically for the myelodysplastic syndromes (MDS), which are distinguished among the blood cancers by their relative indolence in many patients and high rate of transfusion dependence. Methods: We conducted a retrospective analysis using the Surveillance Epidemiology and End Results (SEER)-Medicare database. Patients ≥ 65 years of age who had a primary diagnosis of MDS between 2006 and 2011, lived for at least 30 days after their diagnosis, and died prior to December 31, 2012 were eligible for inclusion. Outcomes were two well-established quality measures for EOL care in oncology (Earle, JCO, 2003; Keating, Cancer, 2010): ICU admission within the last 30 days of life (an indicator of poor quality), and enrollment in hospice for any length of time (an indicator of good quality). After determining their overall prevalence, we fit multivariable logistic regression models to investigate sociodemographic and clinical associations (see table) with each outcome. Results: A total of 6,955 MDS patients were eligible. Overall, 28% were admitted to the ICU in the last month of life, and 49% had enrolled in hospice. In multivariable analyses, transfusion-dependent patients were more likely to be admitted to the ICU and less likely to enroll in hospice (both p<0.001). There was no significant association with marital status or time from diagnosis to death for either outcome. Patients who died in later years had a higher prevalence of ICU admissions (p=0.05) and were more likely to enroll in hospice (p<0.001). Additional multivariable associations are shown below. *Adjusted for all variables listed as well as marital status and time from diagnosis to death Conclusions: Only about half of the MDS patients in our cohort were enrolled in hospice; however, the odds of enrollment increased over time. Interestingly, the odds of ICU admission within the last 30 days of life also increased over time, a trend that has been seen in solid tumors (e.g. Wright, JCO, 2014). As bone marrow failure in MDS can lead to reversible sepsis and the need for temporary blood pressure support, it is difficult to determine if this trend truly represents a worsening in quality of EOL care. Finally, our finding that transfusion-dependent MDS patients were less likely to receive hospice suggests that one reason for suboptimal enrollment is that the current hospice model-which largely disallows transfusions-is not meeting the specific palliative needs of this population. Table 1. Table 1. Disclosures Gore: Celgene: Consultancy, Honoraria, Research Funding. Davidoff:Celgene: Consultancy, Research Funding. Steensma:Incyte: Consultancy; Amgen: Consultancy; Celgene: Consultancy; Onconova: Consultancy.

National trends in end of life care for veterans with advanced cancer.

2018 ◽  
Vol 36 (30_suppl) ◽  
pp. 3-3 ◽  
Author(s):  
Claire Elizabeth Powers Smith ◽  
Pat Coke ◽  
Monica Kluger ◽  
Arif Kamal ◽  
Michael J. Kelley
Keyword(s):  
Lung Cancer ◽  
End Of Life ◽  
Cancer Patients ◽  
Repeated Measures ◽  
Stage Iv ◽  
Health Administration ◽  
Icu Admission ◽  
Chemotherapy Administration ◽  
Stage Iv Lung Cancer ◽  
Eol Care

3 Background: It is imperative to provide quality end of life (EOL) care for cancer patients. This entails minimizing aggressive measures at the EOL. Although rates of hospice utilization within the Veteran’s Health Administration have improved, chemotherapy administration and intensive care unit (ICU) admission at the EOL, indicators of aggressive care, are not clearly declining over recent years. Methods: We identified 32,665 veterans diagnosed with stage IV lung, colorectal, or pancreatic cancer who died between 2009-2016 using VA cancer registry and Corporate Data Warehouse data through a novel EOL Dashboard Tool, which has been validated at multiple VA sites. This EOL tool reports three indicators; incidence of chemotherapy use in the last 14 days of life, ICU admission in the last 30 days of life and hospice admission or consult. Change over time, 2009-2016, was assessed using a repeated measures one-way ANOVA with post hoc test for linear trend of time for individual cancers and two-way ANOVA for all cancers combined. Results: Chemotherapy use in the last 14 days of life declined from 6.8% in 2009 to 4.4% in 2016 (p < 0.05). ICU admission in the last 30 days did not change significantly, from 13.3% in 2009 to 14.7% in 2016. The exception was stage IV lung cancer patients in whom ICU admissions increased from 12.9% to 16.2% (p = 0.01). Patients utilizing hospice services increased from 32.4% to 52.6% (p < 0.01). When combined for all years in an unadjusted analysis by VA regional network (VISN), chemotherapy use ranged geographically from 4.2% to 8.1% and for ICU admission from 8.4% to 18.0%. Conclusions: While chemotherapy administration at the EOL is declining for veterans with stage IV cancer, ICU admissions are unchanged and becoming more common in stage IV lung cancer despite increasing hospice utilization. Compared to prior Medicare reports, veterans have similar rates of EOL chemotherapy use and fewer EOL ICU admissions, adding to a growing body of literature showing that despite veterans having poorer health and utilizing more medical resources, the VA performs at or above non-veteran health care institutions on end of life cancer care. There is notable geographic variation in aggressive EOL care.

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