End-of-life quality metrics among medicare decedents at minority-serving cancer centers: A retrospective study

Abstract

Background: We calculated the performance of National Cancer Institute (NCI)/National Comprehensive Cancer Network (NCCN) cancer centers' end-of-life (EOL) quality metrics among minority and white decedents to explore center-attributable sources of EOL disparities.

Methods: We conducted a retrospective cohort study of Medicare beneficiaries with poor-prognosis cancers who died between April 1, 2016 and December 31, 2016 and had any inpatient services in the last 6 months of life. We attributed patients' EOL treatment to the center at which they received the preponderance of EOL inpatient services and calculated eight risk-adjusted metrics of EOL quality (hospice admission ≤3 days before death; chemotherapy last 14 days of life; ≥2 emergency department (ED) visits; intensive care unit (ICU) admission; or life-sustaining treatment last 30 days; hospice referral; palliative care; advance care planning last 6 months). We compared performance between patients across and within centers.

Results: Among 126,434 patients, 10,119 received treatment at one of 54 NCI/NCCN centers. In aggregate, performance was worse among minorities for ED visits (10.3% vs 7.4%, P < .01), ICU admissions (32.9% vs 30.4%, P = .03), no hospice referral (39.5% vs 37.0%, P = .03), and life-sustaining treatment (19.4% vs 16.2%, P < .01). Despite high within-center correlation for minority and white metrics (0.61-0.79; P < .01), five metrics demonstrated worse performance as the concentration of minorities increased: ED visits (P = .03), ICU admission (P < .01), no hospice referral (P < .01), and life-sustaining treatments (P < .01).

Conclusion: EOL quality metrics vary across NCI/NCCN centers. Within center, care was similar for minority and white patients. Minority-serving centers had worse performance on many metrics.

Keywords: cancer; end-of-life quality; minority; treatment intensity.

© 2019 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.

Figures

Figure 1

Geographic distribution, size, and minority concentration of NCI/NCCI cancer centers. Each bubble is a cancer center. The size of the bubble is proportionate to the total number of decedents assigned to the cancer center in 2016 and the shading of the bubble is proportionate to the concentration of minorities (low: 30%). For an interactive version of this figure, visit [Dartmouth Atlas URL TBD]. [NCI – National Cancer Institute; NCCN – National Comprehensive Cancer Network]

Figure 2

Panels A‐H. Correlation between white and minority‐specific end‐of‐life treatment intensity metrics, by NCI/NCCN cancer center. Panel A represents chemotherapy administration in the last 14 d of life, Panel B two or more emergency department visits in the last 30 d of life, Panel C ICU admissions in the last 30 d of life, Panel D late hospice referrals, Panel E no hospice referrals, Panel F life‐sustaining treatment in last 30 d, Panel G palliative care codes in last 6 mo of life, and Panel H advance care planning codes in the last 6 mo of life. Each bubble is a single cancer center; an “x” mark along the x‐axis represents cancer centers with insufficient sample size to calculate a minority‐specific measure. The y‐axis is the measure among minority decedents and the x‐axis is the measure among white decedents. Those centers with insufficient sample size to calculate either a white or minority‐specific measure are excluded from the panel. Listed in the upper left corner of each panel is N, the numbers of centers with sufficient sample size to calculate minority‐specific metrics. Below that is the correlation (rho) between cancer centers’ minority and white EOL measure and its P‐value. Next is the minority mean and standard deviation (SD) in parenthesis, followed by white mean and SD in parenthesis. The final P‐value is of the mean difference between minority and white EOL measure Reporting full information was restricted to metrics with white and minority‐specific metrics calculable for least 10 centers. [NCI – National Cancer Institute; NCCN – National Comprehensive Cancer Network]