A retrospective study of nonelderly New Jersey Medicaid enrollees with advanced cancer showed higher rates of aggressive end-of-life care for non-Hispanic black patients compared with other racial/ethnic groups. These findings were published in JCO Oncology Practice.
Racial and ethnic disparities regarding the type of end of life care received have been reported for patients with advanced cancer enrolled in Medicare, and include a higher likelihood of aggressive treatment in the last few weeks of life for patients in racial/ethnic minority groups. However, less is known about whether such disparities exist for patients with advanced cancer who are nonelderly Medicaid beneficiaries.
In this study, the New Jersey State Cancer Registry (NJSCR)–Medicaid claims linked database was used to explore end-of-life care in a cohort of patients with advanced breast or advanced colorectal cancer who resided in New Jersey and were aged 21 to 64 years with stage IV disease at the time of first primary cancer diagnosis which occurred between 2011 and 2015. All included patients were continuously enrolled in Medicaid for more than 60 days prior to death with a date of death occurring before February 1, 2016.
Measures of aggressive end-of-life care included more than 1 inpatient hospitalization, more than 1 emergency department visit, and any intensive care unit (ICU) admission within 30 days prior to death, receipt of chemotherapy within 14 days of death, as well as a composite measure that combined those 4 criteria. Data regarding whether patients had been enrolled in a hospice program at any time prior to death and in the last 3 days of life were also collected.
The median survival of the 349 patients included in the study was 14 months. Nearly half of patients were enrolled in Medicaid for less than 1 month in the year prior to cancer diagnosis, and self-reported race/ethnicity was non-Hispanic white, non-Hispanic black, Hispanic, and non-Hispanic Asian Pacific Islander for 44%, 33%, 18%, and 5% of patients, respectively.
At least one measure of aggressive end of life care was observed for 73% of non-Hispanic black patients, 60% of non-Hispanic white patients, 59% of non-Hispanic Asian Pacific Islanders, and 48% of Hispanic patients. Following adjustments for clinical and sociodemographic characteristics, and using non-Hispanic white patients as a comparator group, non-Hispanic black patients were significantly more likely to have received any type of aggressive end-of-life care (odds ratio [OR], 1.87; 95% CI, 1.07-3.26), and to have undergone more than 1 hospitalization (OR, 1.98; 95% CI, 1.13-3.47), and more than 1 emergency department visit (OR, 1.79; 95% CI, 1.05-3.06) within 30 days of death.
Regarding these findings, the study authors pointed out that although “all patients in our study were low-income Medicaid beneficiaries, black patients were twice as likely to receive aggressive [end-of-life] care compared with [non-Hispanic] white patients.”
Rates of any enrollment in hospice care were 42% for non-Hispanic white patients, 43% for non-Hispanic black patients, 35% for Hispanic patients, and 29% for non-Hispanic Asian Pacific Islanders, respectively; there was no significant difference by race/ethnicity group, and rates of hospice enrollment within 3 days of death were below 20% in all groups.
“Strategies to increase awareness of community preferences for [end of life] care at the provider, health system, and policy levels, as well as strengthening communication strategies between clinicians and patients, are needed to achieve optimal [end-of-life] care for low-income and vulnerable populations,” the study authors commented in their concluding remarks.
Yang A, Goldin D, Nova J, Malhotra J, Cantor JC, Tsui J. Racial disparities in health care utilization at the end of life among New Jersey Medicaid beneficiaries with advanced cancer [published online April 16, 2020]. JCO Oncol Pract. doi: 10.1200/JOP.19.00767