Racial and ethnic differences in end-of-life care in fee-for-service Medicare beneficiaries with advanced cancer

Abstract

Objectives: To examine racial and ethnic variation in use of hospice and high-intensity care in patients with terminal illness.

Design: Retrospective, secondary data analysis.

Setting: Surveillance, Epidemiology, and End Results-Medicare Database from 1992 to 1999 with follow-up data until December 31, 2001.

Participants: Forty thousand nine hundred sixty non-Hispanic white, non-Hispanic black, Asian, and Hispanic fee-for-service Medicare beneficiaries aged 65 and older with advanced-stage lung, colorectal, breast, and prostate cancer.

Measurments: Hospice use and indicators of high-intensity care at the end of life.

Results: Whereas 42.0% of elderly white patients with advanced cancer enrolled in hospice, enrollment was lower for black (36.9%), Asian (32.2%), and Hispanic (37.7%) patients. Differences between white and Hispanic patients disappeared after adjustment for clinical and sociodemographic factors. Higher proportions of black and Asian patients than of white patients were hospitalized two or more times (11.7%, 15.0%, 13.7%, respectively), spent more than 14 days hospitalized (11.4%, 17.4%, 15.6%, respectively), and were admitted to the intensive care unit (ICU) (12.0%, 17.0%, 16.2%, respectively) in the last month of life and died in the hospital (26.5%, 31.3%, 33.7%, respectively). Unadjusted differences in receipt of high-intensity care according to race or ethnicity remained after adjustment.

Conclusion: Black and Asian patients with advanced cancer were more likely than whites to be hospitalized frequently and for prolonged periods, be admitted to the ICU, die in the hospital, and be enrolled in hospice at lower rates. Further research is needed to examine the degree to which patient preferences or other factors explain these differences.

Figure 1

For each measure of high-intensity care at the end of life, P<.001 for differences according to race or ethnicity.