Determining the racial disparities in utilization and cost of care at the end-of-life and survival for the elderly with lung cancer

Background: The objective of the study was to estimate the racial disparities in the quality of care and cost during the end-of-life, and racial disparities in the survival of patients with lung cancer. Methods: A longitudinal study was conducted with patients ≥66 years diagnosed with stage I-IV lung cancer using the SEER-Medicare data from 1991-2011. Quality of care was measured using eight variables for hospital stay, ICU care, ER care, hospice, chemotherapy, death in acute care hospital and overall aggressive care in the last month of life. We estimated the direct medical cost of care in the last 6 months of life from a health care payer’s perspective. The patients were divided into Non-Small Cell Lung Cancer (NSCLC) and Small Cell Lung Cancer (SCLC) cohorts. Multivariate logistics regression analyses were performed to determine the association of the quality of care variables and race. An Ordinary least squares (OLS) regression followed by a Blinder-Oaxaca decomposition using the logarithm of cancer care cost in the last 6 months of life were performed to estimate the proportion of disparity in cost between NH-Black and NH-White patients. Proportional odds model with log-logistic distribution was used to estimate the relative odds of survival. Adjusted mortality rates were calculated using a Poisson regression model and decomposition of mortality rates was conducted. Results: A higher odds of dying in an acute care setting, having \u3e1 ER visit, \u3e 1 hospital stay and ICU stay in last 30 days, and a lower odds of starting a new chemotherapy regimen in the last 30 days of life, and receiving any chemotherapy in the last 14 days of life was seen in Non-Hispanic (NH)-Black patients with NSCLC. Overall, the likelihood of aggressive care was higher for NH-Black with NSCLC patients. The OLS regressions showed that NH-Blacks had higher costs than NH-Whites. The decomposition also showed that only 30-31% of the differences in cost between NH-Blacks and NH-Whites were explained by the variables used in the analysis. The differences due to SEER regions accounted for a high proportion of the explained difference. The proportional odds model showed that NH-Blacks had higher odds of surviving than NH-Whites with NSCLC and SCLC. The Poisson regression model showed that the rate of death for NH-Black patients with NSCLC was higher than NH-Whites, and the estimated difference was 55 deaths per 100,000 patients per day. Decomposition showed that the difference in census-tract college education and stage each accounted for 20% of the explained difference in the rate of death between NH-Blacks and NH-Whites with NSCLC. Conclusion: The study found that end-of-life care differed by race among patients with lung cancer. The racial minorities with NSCLC received aggressive treatment indicative of poor quality near end-of-life. The cost for lung cancer patients during the last 6 months of life was higher in NH-Blacks compared to NH-Whites. Further, the mortality rates were higher for NH-Blacks than NH-Whites. However, the survival for NH-Blacks was better than NH-Whites when the model was controlled for socio-demographic and tumor characteristics.