Black patients with ovarian cancer received lower quality end-of-life care, research shows

Non-Hispanic Black patients (NHB) with ovarian cancer (OC) received lower quality end-of-life care than non-Hispanic White patients (NHW), according to a study published in Communication about cancer research.

The researchers explained that the benefits of high-quality EOL care include better symptom management, improved quality of life, and dramatically reduced healthcare costs. However, many patients do not receive this approach because high-quality EOL care is characterized by racial disparities at both the regional and national levels.

Although trends and disparities in EOL care among patients with OC are well documented, the researchers noted that the role of access to health care (HCA) in high-quality EOL care is not well characterized; HCA consists of five different, interrelated dimensions of healthcare access, namely affordability, availability, accessibility, accommodation and acceptability.

Consequently, among NHW, NHB, and Spanish-speaking patients with OC, they aimed to investigate the association of 3 HCA domains, namely availability (type, quality, and quantity of healthcare facilities), accessibility (proximity to healthcare facilities for a patient). and affordability (the ability to pay for health care), with racial disparities in the quality of EOL care.

Hospital bed | Image credit: cat syrup – stock.adobe.com

To do this, researchers analyzed NHB, NHW, and Spanish-speaking women aged 65 years or older within the Surveillance, Epidemiology, and End Results (SEER)-Medicare database who were diagnosed with OC between 2008 and 2015. Eligible patients survived at least 30 days after their initial OC diagnosis and died by December 31, 2016; they were also continuously enrolled in Medicare fee-for-service (FFS) parts A and B for at least 1 year before diagnosis and had continuous FFS coverage from diagnosis until death.

To identify the most influential variables of each HCA aspect, the researchers conducted a confirmatory factor analysis (CFA). Through this analysis, they created composite scores ranging from –3 to 4 to characterize the availability, accessibility, and affordability of quality EOL care for each patient.

Lower availability scores meant that patients had fewer local hospitals and doctors, as well as lower average hospital quality. Lower accessibility scores also caused patients to travel greater distances to health care facilities, and lower affordability scores indicated that patients lived in areas with higher poverty rates or lower education levels.

The study population consisted of a total of 4646 patients with OC with a mean (standard deviation (SD)) age of 77.5 (7.0) years. More specifically, the group consisted of 4061 (87.4%) NHW patients, 322 (6.9%) NHB patients, and 263 (5.7%) Spanish-speaking patients. Of the study population, most (N = 4176; Stage III or IV OC was diagnosed in 89.9%).

The researchers found that 42.9% of the study population was hospitalized in the last month of life. Of the admitted patients, the majority were NHB patients (53.7%), followed by Spanish-speaking (43.7%) and NHW patients (42.0%). Before death, 30.9% of the study population did not use hospice. This consisted of 30.1% NHW patients, 35.7% NHB patients, and 37.3% Spanish-speaking patients. Ultimately, 19.05% of the population died in hospital; NHB (24.8%) and Hispanic (25.8%) patients made up a relatively higher proportion of this percentage than NHW patients (18.1%; P <.001). Based on their findings, researchers concluded that NHB and Hispanic patients with OC had slightly higher mean counts of poor-quality EOL care outcomes (NHB mean count, 1.59; Hispanic, 1.46; NHW, 1.29 ; P <.001).

Additionally, through their CFA, the researchers found that higher affordability scores were associated with a 9% lower risk of in-hospital death (adjusted relative risk (aRR), 0.91; 95% CI, 0.84-0.98) and a 10% lower risk of an intensive care stay in the last 30 days of life (aRR, 0.90; 95% CI, 0.83-0.98). Also, those with higher availability scores had an 11% increased risk of in-hospital death (aRR, 11.11; 95% CI, 1.02-1.20) and a 7% increased risk of hospitalization in the last 30 days of their life (aRR, 1.07). 95% CI, 1.02-1.12). Finally, those with higher accessibility scores had a 54% lower risk of two or more ED visits in the last 30 days of life (OR, 0.46; 95% CI, 0.35-0.62), a 12% lower risk of not receiving hospice services before death (aRR, 0.88; 95% CI, 0.80-0.95), and a substantially increased risk of ICU stay (aRR, 1.35; 95% CI, 1 ,14-1.60).

After adjusting for HCA dimensions, investigators reported that NHB patients with OC were at increased risk for frequently poor EOL care outcomes compared with NHW patients, as they had 19% higher rates of poor-quality EOL outcomes (number ratio, 1.19 ; 95% CI, 1.04-1.36). More specifically, NHB patients with OC had an increased risk of hospitalization in the last 30 days of life (aRR, 1.16; 95% CI, 1.03-1.30) and of not receiving hospice care before death ( aRR, 1.23; 95% CI, 1.04-1.44), and of in-hospital mortality (aRR, 1.26; 95% CI, 1.03-1.57).

The researchers acknowledged the limitations of their study, including that the study population consisted of patients aged 65 or older, so their findings may not be generalizable to younger patients. Also, the reported patterns of racial disparities in EOL care may reflect the study period, which was from 2008 to 2015. Despite these limitations, the researchers suggested areas for future research based on their findings.

“Further research on fit and acceptability of HCA dimensions may shed light on poorly researched barriers to high-quality EOL,” the authors conclude. “Our findings demonstrate the need for strategies to standardize the receipt of supportive care, palliative care, and EOL care for terminally ill patients with OC, regardless of race and ethnicity.”

Reference

Karanth S, Osazuwa-Peters OL, Wilson LE, et al. Dimensions of access to health care and racial disparities in the quality of end-of-life care in patients with ovarian cancer. Cancer Research Comm. 2024;4(3):811-821. doi:10.1158/2767-9764.CRC-23-0283