DOES AN INCREASE IN HOSPICE USE DECREASE RACIAL DIFFERENCES IN END-OF-LIFE CANCER CARE INTENSITY

Purpose: Hospice use has increased dramatically in the United States since last decade. This study aims to examine current racial differences in end-of-life care expenditures and intensity among cancer decedents, and to compare the findings in prior literature based on data in an era with low hospice use. 

Method(s): Using the Surveillance, Epidemiology, and End Results–Medicare data, we identified 88,751 beneficiaries who died from breast, prostate, lung, colorectal, pancreas, liver, kidney, melanoma, or hematological cancer within 3 years of cancer diagnosis from 2006 to 2011. We calculated last month of life healthcare expenditure and end-of-life care intensity, measured by 1) chemotherapy received within 14 days of death; 2) >1 emergency department (ED) visit or hospitalization within 30 days of death; 3) ≥1 intensive care unit (ICU) admission within 30 days of death; 4) in-hospital death; or 5) hospice enrollment ≤3 days before death. The magnitudes of racial differences in end-of-life care intensity were compared with the published results based on similar population from 1992 to 2001.

Result(s): The mean expenditure on end-of-life cancer care per decedent in the last month of life was $10,400 for Whites, $12,300 for Blacks, $12,900 for Hispanics, and $14,500 for Asians. Approximately 70.6% of White decedents enrolled in hospice; whereas enrollment was lower for Blacks (62.9%) and Asians (53.5%). Higher proportions of Asian and Black decedents than of White decedents had >1 hospitalization (17.1%, 17.4%, 13.8%, respectively), >1 ED visit (39.5%, 42.2%, and 34.1%, respectively), were admitted to the ICU (27.9%, 23.4%, 17.2%, respectively) in the last month of life and died in the hospital (35.7%, 26.1%, 20.7%, respectively). However, Asian and Black decedents, compared with White decedents, were less likely to receive late chemotherapy (3.2%, 3.3%, 4.2%, respectively) and have late hospice enrollment (5.7%, 6.9%, 8.5%, respectively). These racial differences remained after adjustment. Compared with the findings of 1992-2001, hospice use almost doubled across all groups, and end-of-life care intensity generally increased. The magnitude regarding racial differences in the proportion of decedents who had ICU admission or repeated ED visit increased substantially.

Conclusion(s): Asian and Black cancer decedents were more likely to receive aggressive end-of-life care than White decedents and incurred higher end-of-life expenditures. Recent increase in hospice use did not mitigate racial differences in end-of-life care intensity.