Black Patients With Ovarian Cancer Had Lower-Quality End-of-Life Care, Study Says

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

The researchers explained that the benefits of high-quality EOL care include better symptom management, improved quality of life, and drastically lower health care costs. However, many patients do not receive this approach, as quality EOL care is characterized by racial disparities at both 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 health care access (HCA) in quality EOL care has not been well characterized; HCA is comprised of 5 distinct, interrelated care access dimensions, namely affordability, availability, accessibility, accommodation, and acceptability.

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

Hospital bed | Image Credit: catinsyrup - stock.adobe.com

To do so, the researchers analyzed NHB, NHW, and Hispanic 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 for at least 30 days following their initial OC diagnosis and died by December 31, 2016; they also were 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 performed 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 high-quality EOL care for each patient.

Lower availability scores meant the patients had fewer numbers of local hospitals and physicians, as well as lower-average hospital quality. Also, lower accessibility scores meant the patient traveled greater distances to health care facilities, and lower affordability scores indicated that patients lived in areas with higher poverty rates or lower educational levels.

The study population consisted of 4646 total patients with OC with a mean (standard deviation [SD]) age of 77.5 (7.0) years. More specifically, it was made up of 4061 (87.4%) NHW patients, 322 (6.9%) NHB patients, and 263 (5.7%) Hispanic patients. Of the study population, most (N = 4176; 89.9%) were diagnosed with stage III or IV OC.

The researchers found that 42.9% of the study population was admitted to the hospital in their last month of life. Of those admitted, most were NHB patients (53.7%), followed by Hispanic (43.7%) and NHW (42.0%) patients. 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% Hispanic patients. Ultimately, 19.05% of the population died in the hospital; NHB (24.8%) and Hispanic (25.8%) patients made up relatively higher proportions of this percentage than NHW patients (18.1%; P < .001). Based on their findings, the researchers concluded that NHB and Hispanic patients with OC had slightly higher average 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 determined that higher affordability scores were associated with a 9% decreased risk of dying in the hospital (adjusted relative risk [aRR], 0.91; 95% CI, 0.84-0.98) and a 10% decreased risk of an ICU 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 dying in the hospital (aRR, 11.11; 95% CI, 1.02-1.20) and a 7% increased risk of hospitalization in the last 30 days of life (aRR, 1.07; 95% CI, 1.02-1.12). Lastly, those with higher accessibility scores had a 54% reduced risk of 2 or more ER visits in the last 30 days of life (OR, 0.46; 95% CI, 0.35-0.62), a 12% reduced 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, the researchers reported that NHB patients with OC were at an increased risk of common poor EOL care quality outcomes compared with NHW patients as they had 19% higher counts of poor-quality EOL outcomes (count ratio, 1.19; 95% CI, 1.04-1.36). More specifically, NHB patients with OC were at an increased risk of hospitalization in the last 30 days of life (aRR, 1.16; 95% CI, 1.03-1.30), of not receiving hospice care before death (aRR, 1.23; 95% CI, 1.04-1.44), and of in-hospital death (aRR, 1.26; 95% CI, 1.03-1.57).

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

“Further investigations on accommodation and acceptability HCA dimensions can shed light on poorly explored barriers to high-quality EOL,” the authors concluded. “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 irrespective of race and ethnicity.”

Reference

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