Disparities Of Palliative Care Utilization Research Articles

Trends, Predictors, and Potential Disparities of Palliative Care Utilization Among Older Adults With Hip Fractures: A Retrospective Analysis of the National Inpatient Sample, 2016-2020.

Objectives: To assess the trends in palliative care consultation utilization and identify associated factors among older adults hospitalized with hip fractures in the United States between 2016 and 2020. Methods: We conducted a retrospective cohort study using data from the National Inpatient Sample from 2016 to 2020. The study included patients aged 65 and older admitted to hospital with a primary diagnosis of hip fracture. We identified palliative care consultations using ICD-10 code Z51.5. Multivariate logistic regression analyses were performed to identify predictors of palliative care utilization, adjusting for demographics, clinical variables, and hospital characteristics. Results: A total of 293,749 admissions for hip fractures were identified, of which 9546 (3.2%) had palliative care consultations. A consistent upward trend was seen in the proportion of patients receiving palliative care consultations across all fracture types. Patients of color (Black: odds ratio [OR] = 0.73, 95% confidence interval [CI]: 0.65-0.83; Hispanic: OR = 0.67, 95% CI: 0.60-0.75 compared to White), those in lower-income quartiles (lowest: OR = 0.81, 95% CI: 0.76-0.87 compared to highest), smaller hospital size (OR = 0.84, 95% CI: 0.79-0.89 compared to large), and rural hospital (OR = 0.63, 95% Cl: 0.59-0.68, compared to urban teaching) were associated with fewer palliative care consultations. Conclusion: The number of palliative care consultations during hip fracture hospital admission was low, although the proportion increased over time. Significant disparities were observed and further research should explore barriers to palliative care access and develop strategies to enhance its delivery across diverse healthcare settings.

Prevalence and Factors Associated With Palliative Care Utilization Among Hospitalized Patients With Gallbladder Cancer- A National Inpatient Sample Analysis.

Various factors have been associated with palliative utilization in different cancers. However, literature is still lacking on the prevalence and factors associated with palliative care use in gallbladder cancer (GBC). This study aims to determine the prevalence of palliative care utilization and examine the factors associated with palliative care utilization among patients with GBC. We conducted a retrospective analysis using the National Inpatient Sample between 2016 and 2018. Descriptive statistics were used to characterize the study population. We explored factors associated with palliative care utilization among hospitalized GBC patients using logistic regression. Of the 20280 GBC hospitalizations, 18.0 % utilized palliative care. Multivariable analysis revealed that treatment at urban teaching hospitals, or treatment at urban nonteaching hospitals, Medicare insurance, other insurance coverage, transfer to a facility/discharge with home health, and death during hospital stay were associated with higher utilization of palliative care. In contrast, non-elective admissions were associated with decreased odds of palliative care utilization. Palliative care use among GBC patients is still low at 18.0%. Palliative care use was associated with insurance disparities, discharge disposition, hospital location, and type of admission. Therefore, concerted efforts to address these disparities in palliative care utilization are needed to improve the quality of care for this population.

Exploring disparities in palliative care utilization among hospitalized patients with hepatocellular carcinoma: A retrospective cohort study.

1616 Background: Hepatocellular carcinoma is one of the common gastrointestinal cancers, and its advanced stage requires palliative care due to its inferior prognosis and mortality. Palliative care significantly improves the burden of HCC on patients and the healthcare system. Despite the evidence of its use, reported utilization could have been better. This study aims to investigate the disparities in utilization of palliative care in hospitalized patients with HCC and examine related factors. Methods: This retrospective cohort study used data from the 2018-2020 National Inpatient Sample (NIS) database. Patients aged 18 or above with hepatocellular carcinoma were studied to determine how their utilization of palliative care varied based on their race and other identifiable risk factors. Palliative care utilization encompasses palliative care/ comfort care or under the care of a palliative care physician or referral. We examined these patients' demographics, All Patient Refined Diagnosis Related Group (APR-DRG) risk of mortality, and their relationship with palliative care utilization. Results: This study identified 128,140 patients with hepatocellular carcinoma (HCC), of whom 26,730 (20.9%) had utilized palliative care. The majority of study participants were White and male. The palliative care utilization (PCU) group comprised mainly White patients, with 50% of the group having extreme APR-DRG risk of mortality. Compared to Whites, Blacks had increased odds of palliative care utilization in both unadjusted (OR=1.08; 95% CI: 0.99-1.18) and adjusted models (aOR=1.11; 95% CI: 1.01-1.22). Hispanics had reduced odds in both unadjusted (OR=0.83; 95% CI: 0.75-0.91) and adjusted models (aOR=0.84; 95% CI: 0.76-0.93). Moreover, over 50% of study participants were in large, bed-sized hospitals and on Medicare insurance. Conclusions: Our study showed significant disparities in palliative care utilization among hospitalized patients with hepatocellular carcinoma. While the majority of patients were White and male, Black patients had increased odds of palliative care utilization, and Hispanics had reduced odds. Additionally, patients in large, bed-sized hospitals and on Medicare insurance comprised over 50% of the study population. The racial disparities in utilization might stem from differences in socio-cultural beliefs and practices alongside other factors. Efforts are needed to address these disparities and ensure equitable care for all patients, particularly vulnerable populations. Further research and quality improvement initiatives are essential to explore and address these disparities and contributing factors, enhancing outcomes for patients with HCC.

Trends and racial disparities in palliative care utilization among patients with prostate cancer: A ten-year retrospective study.

Trends and racial disparities in palliative care utilization among patients with prostate cancer: A ten-year retrospective study.

Rural-urban disparities and trends in utilization of palliative care services among US patients with metastatic breast cancer.

To assess trends and rural-urban disparities in palliative care utilization among patients with metastatic breast cancer. We analyzed data from the 2004-2019 National Cancer Database. Palliative care services, including surgery, radiotherapy, systemic therapy, and/or other pain management, were provided to control pain or alleviate symptoms; utilization was dichotomized as "yes/no." Rural-urban residence, defined by the US Department of Agriculture Economic Research Service's Rural-Urban Continuum Codes, was categorized as "rural/urban/metropolitan." Multivariable logistic regression was used to examine rural-urban differences in palliative care use. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated. Of 133,500 patients (mean age 62.4 [SD=14.2] years), 86.7%, 11.7%, and 1.6% resided in metropolitan, urban, and rural areas, respectively; 72.5% were White, 17.0% Black, 5.8% Hispanic, and 2.7% Asian. Overall, 20.3% used palliative care, with a significant increase from 15.6% in 2004-2005 to 24.5% in 2008-2019 (7.0% increase per year; p-value for trend <0.001). In urban areas, 23.3% received palliative care, compared to 21.0% in rural and 19.9% in metropolitan areas (p<0.001). After covariate adjustment, patients residing in rural (AOR=0.84; 95% CI: 0.73-0.98) or metropolitan (AOR=0.85, 95% CI: 0.80-0.89) areas had lower odds of having used palliative care than those in urban areas. In this national, racially diverse sample of patients with metastatic breast cancer, the utilization of palliative care services increased over time, though remained suboptimal. Further, our findings highlight rural-urban disparities in palliative care use and suggest the potential need to promote these services while addressing geographic access inequities for this patient population.

Palliative Care Use Trends, Racial/Ethnic Disparities, and Overall Survival Differences Among Patients With Metastatic Breast Cancer.

Background: Palliative care improves cancer patients' quality of life. Limited research has investigated racial/ethnic disparities in palliative care utilization and its associated survival among metastatic breast cancer (MBC) patients. Objectives: To examine racial/ethnic palliative care use disparities and assess racial/ethnic overall survival differences in MBC patients stratified by palliative care use. Design: A retrospective study of MBC patients from the 2004-2020 National Cancer Database. Measurements: Palliative care was defined as noncurative cancer treatment, including surgery, radiotherapy, systemic therapy, and/or pain management; utilization was coded "yes/no." Racial/ethnic groups included Asian, American Indian or Alaska Native (AIAN), Black, Hawaiian or Other Pacific Islander (HPI), Hispanic, and White. Logistic regression was performed to assess palliative care use disparities. Overall survival was modeled using Cox regression. Results: Of 148,931 patients, the mean age was 62 years; 99% were female; 73% identified as White, 17% as Black, 6% as Hispanic, 3% as Asian, 0.3% as AIAN, and 0.3% as HPI; 42% and 39% had Medicare and private insurance, respectively. Overall, 21% used palliative care, with an increasing utilization rate from 2004 to 2020 (3.6% increase per year, p-trend <0.001). Black (adjusted odds ratio [aOR] = 0.89; 95% confidence interval [CI]: 0.84 to 0.94), Asian (aOR = 0.76; 95% CI: 0.68 to 0.86), and Hispanic (aOR = 0.68; 95% CI: 0.62 to 0.74) patients had a lower likelihood of palliative care utilization than White patients. Among palliative care users, compared with White patients, Black (adjusted hazard ratio [aHR] = 1.14, 95% CI: 1.07 to 1.21) patients had a greater mortality risk, while Asian (aHR = 0.83, 95% CI: 0.71 to 0.97) and Hispanic (aHR = 0.77, 95% CI: 0.69 to 0.87) patients had a lower mortality risk. Conclusions: Palliative care utilization among MBC patients significantly increased but remained suboptimal. Racial/ethnic minority patients were less likely to use palliative care, and Black patients had worse survival, than White patients, suggesting the need for improving palliative care access and ameliorating disparities in MBC patients.

Racial/ethnic disparities in inpatient palliative care utilization and hospitalization outcomes among patients with colorectal cancer.

Research has shown that racial/ethnic disparities exist in outcomes for colorectal cancer (CRC) patients, but there are no studies assessing inpatient palliative care utilization and hospitalization outcomes in this population. We examined racial/ethnic disparities in palliative care utilization and hospitalization outcomes among CRC and early-onset CRC patients. Using National Inpatient Sample (NIS) data collected between 2016 and 2018, cross-sectional analyses were performed. Descriptive analyses were done, stratified by race/ethnicity. Multivariable logistic and linear regression models were used to examine racial/ethnic differences in palliative care utilization, inpatient mortality, chemotherapy/radiotherapy use, length of stay and total hospital charges among hospitalized patients with CRC and early-onset CRC. Blacks had higher odds (AOR: 1.09; 95% CI: 1.03-1.16) of receiving palliative care consultation while Hispanics had lower odds (AOR: 0.90; 95% CI: 0.84-0.96) compared to Whites. Blacks had 1.1 times higher odds (95% CI: 1.01-1.18) of inpatient mortality relative to Whites while Hispanics had 16% (AOR: 0.84; 95% CI: 0.76-0.93) lower odds of inpatient mortality. Compared to Whites, Blacks (AOR: 1.99; 95% CI: 1.64-2.41), Hispanics (AOR: 2.49; 95% CI: 1.94-3.19) and colorectal cancer patients in the other category (AOR: 1.72; 95% CI: 1.35-2.18) were more likely to receive inpatient treatment with chemotherapy/radiotherapy. Furthermore, Black patients were 1.1 times (95% CI: 1.06-1.14) more likely to have a length of stay more than 5 days. Blacks (𝛃: $3,096.7; 95% CI: $1,207.0-$4,986.5) Hispanic (𝛃: $10,237.5; 95% CI: $7,558.2-$12,916.8) and other patients (𝛃: $6,332.0; 95% CI: $2,830.9-$9, 833.2) had higher hospital charges relative to their White counterparts. Among patients with early onset CRC, Blacks had higher palliative care use (AOR: 1.29; 95% CI: 1.10-1.51) and inpatient mortality (AOR: 1.38; 95% CI: 1.06-1.79) while Hispanics reported $5,589.7 (95% CI: $683.2-$10,496.2) higher total hospital charges and were more likely to receive inpatient chemotherapy/radiotherapy (AOR: 2.48; 95% CI: 1.70-3.63). Further research is needed to explore specific cultural, socioeconomic, and political factors that explain these disparities and identify ways to narrow the gap. Meanwhile, the healthcare sector will need to assess what strategies might be helpful in addressing these disparities in outcomes in the context of other socioeconomic and cultural factors that may be affecting the patients.

Disparities in Palliative Care Utilization in Deceased Lymphoma Patients: A Nationwide Analysis

Objective: The objective of this study was to examine the characteristics and utilization patterns of palliative care among lymphoma cancer patients using a large-scale representative population-based sample. Methods: Retrospective analysis was conducted on hospitalization data from the National Inpatient Sample (NIS) spanning January 2016 to December 2019. The study aimed to investigate the characteristics and disparities associated with the provision of palliative care to deceased lymphoma patients and evaluate its impact on healthcare utilization, specifically discounted hospital charges and length of stay (LOS). Multivariate linear and logistic regression analyses were performed, stratifying the data based on age, race, Charlson comorbidity index, insurance status, median household income, and hospital characteristics. The study population was classified and identified using ICD-10 codes. Results: We identified 10,323 deceased lymphoma patients from hospitalization records, among whom 52.9% (n=5,464) received palliative care during their hospital stay. Multivariate linear regression analysis demonstrated that the group receiving palliative care had significantly lower total charges, with a mean decrease of $24,269 (95% CI: $37,263 to $11,277, p &amp;lt; 0.001) compared to the group not receiving palliative care. However, there was no statistically significant difference in the adjusted length of stay between patients who received palliative care and those who did not (coefficient = -0.07 days, 95% CI = -0.69 to 0.54, p = 0.806). Multivariate logistic regression analysis indicated that patients with Black and Hispanic race had lower odds of receiving palliative care, while those admitted to larger and urban teaching hospitals had higher odds of receiving palliative care. Additionally, patients with Medicare had the lowest probability of receiving palliative care compared to other insurance groups. Conclusion: This study provides valuable insights into the utilization patterns and characteristics associated with palliative care among deceased lymphoma patients. The findings demonstrate that receiving palliative care is associated with significantly lower total charges, indicating its potential cost-saving benefits in healthcare utilization. However, no significant difference was observed in the adjusted length of stay between patients who received palliative care and those who did not. Furthermore, the study highlights disparities in access to palliative care, with Black and Hispanic patients having lower odds of receiving such care. Hospital characteristics, such as size and urban teaching status, were found to influence the likelihood of palliative care utilization. Additionally, patients with Medicare insurance had the lowest probability of receiving palliative care compared to other insurance groups. These findings underscore the need to address disparities in access to palliative care and ensure equitable provision for all lymphoma patients, irrespective of race or insurance status. Integrating palliative care into the treatment approach for lymphoma patients has the potential to optimize healthcare utilization and improve patient outcomes. Policymakers should consider these findings to enhance resource allocation and promote equitable access to palliative care services. Further research and implementation efforts are warranted to improve access and enhance the delivery of palliative care for lymphoma patients.

Race/ethnicity and sex: Assessment of trends and disparities in palliative care utilization among patients with de novo metastatic breast cancer.

82 Background: Palliative care services (PCS) have been shown to improve the quality of life of patients (pts) with late-stage cancers; however, they remain underutilized. Further, national trends and racial/ethnic disparities in PCS use among metastatic breast cancer pts by sex are unclear. Methods: We analyzed data from pts with de novo metastatic breast cancer in the 2004-2019 National Cancer Database (NCDB), a joint project of the Commission on Cancer of the American College of Surgeons and American Cancer Society. Per NCDB, PCS, including surgery, radiotherapy, systemic therapy, and/or pain management, were performed to manage pain or symptoms/side effects; use was categorized as “yes/no.” Racial/ethnic groups included non-Hispanic (NH) Asian, NH Black, Hispanic, and NH White. Sex was reported as “female/male” per NCDB. Trends in PCS use were evaluated. Multivariable logistic regression models were fit to assess racial/ethnic disparities in PCS use by sex. Results: Of 134,943 pts (mean age 62 years [SD=14]), 98.6% were female. Most (74.1%) were NH White, followed by 17.2% NH Black, 5.9% Hispanic, and 2.7% NH Asian. Sociodemographic and clinicopathologic factors differed significantly across racial/ethnic groups. Overall, 20.3% used PCS, with a significant increase from 15.6% in 2004-2005 to 24.6% in 2018-2019 ( p trend &lt;.001). The percentage of PCS use was 20.3% in female pts, with a significant increase from 15.7% in 2004-2005 to 24.6% in 2018-2019 ( p trend &lt;.001). Similarly, 20.2% of male pts used PCS, with a significant increase from 12.7% in 2004-2005 to 24.1% in 2018-2019 ( p trend &lt;.001). 21.0 % of NH White, 19.5% of NH Black, 17.1% of NH Asian, and 15.2% of Hispanic female pts used PCS; and 21.5% of NH White, 16.9% of NH Black, 15.4% of NH Asian, and 15.0% of Hispanic male pts did. In the adjusted regression models, NH Black (adjusted odds ratio [AOR]=0.88, 95% CI: 0.84-0.92, p&lt;.001), NH Asian (AOR=0.74, 95% CI: 0.67-0.81, p&lt;.001), and Hispanic (AOR=0.64, 95% CI: 0.59-0.69, p&lt;.001) female pts were less likely to have used PCS than NH White female pts. NH Black male pts were less likely to have used PCS than their White male counterparts (AOR=0.57, 95% CI: 0.39-0.82, p=.002). Although Hispanic (AOR=0.67, 95% CI: 0.34-1.32, p=.246) and NH Asian (AOR=0.47, 95% CI: 0.16-1.36, p=.166) male pts were also less likely than NH White male pts to have used PCS, these differences were not statistically significant. Conclusions: The current study reports a low prevalence of PCS utilization, though with significant increases from 2004-2005 to 2018-2019, and highlights racial/ethnic disparities in utilization among pts with de novo metastatic breast cancer, regardless of sex. Equity-focused cancer supportive care programs should consider improving the utilization of, and equitable access to, PCS in this patient population, particularly in racial/ethnic minority communities.

Black voices on gynecologic cancer: Understanding experiences.

e18680 Background: Structural racism and bias affects care of Black gynecologic cancer patients. Factors associated with disparities in Black cancer death rates have been associated with structural racism which has systematically limited the standard of living (wealth, housing, education, healthy food and healthcare) for Black people. Recent studies point to implicit bias, and lack of cultural sensitivity playing a significant role in the health outcomes of Black cancer patients. For instance, despite NCCN guidelines, oncologists underprescribe chemotherapy for older Black women with ovarian cancer and underdose chemotherapy for Black women with cervical cancer. Moreover, Black women dying from advanced uterine cancer are given pain medication at lower rates &amp; there are disparities in palliative care utilization amongst Black patients with metastatic gynecologic cancer. The voices of Black patient advocates are frequently missing from research studies. By centering the voices of Black patient advocates, we can identify new means of addressing &amp; positively impacting disparities within the clinical care spectrum (from diagnosis to survivorship). Our study group, Black Voices on Gynecologic Cancer: Understanding Experiences, aimed to identify common and unique scenarios of racism and bias in the experiences of Black patients with gynecologic cancer seeking medical attention. Methods: Focus groups were advertised using social media and partner patient advocacy organizations. We conducted five focus groups of 24 Black gynecologic cancer survivors using a Zoom platform. Key themes were identified through individual and group review of transcripts. Results: The themes that emerged from the focus groups included: (1) lack of communication and/or clarity in patient/provider communication - “… my first appointment with my gyn I did…share that…I'm having these hot flashes, night sweats…so he gave me some medicine, but… they´d never really addressed and had a conversation about like this is what your body will be experiencing…So, I really have been dependent on other women that have gone through this.”, (2) insufficient mental health support throughout and after treatment, (3) experiences with misdiagnosis (4) provider’s inadequate management of patient pain, (5) failure to mention clinical trials and (6) difficulty navigating insurance. Conclusions: Our study identified gaps in the care of Black gynecologic cancer patients. The second phase of BVOGUE will reduce structural barriers that prohibit authentic patient and community engagement around gynecologic cancer care and participation in academic research for Black cancer patients. We will pilot modules for both cancer education and research advocacy. This model will serve as a roadmap for all cancer centers creating action plans for engagement, inclusion, and participation.

Racial and Other Disparities in Palliative Care Utilization (QI122)

Racial and Other Disparities in Palliative Care Utilization (QI122)

Disparities in palliative care utilization in cholangiocarcinoma patients: A National Cancer Database (NCDB) study.

e24077 Background: Cholangiocarcinoma is an adenocarcinoma of the intra- and extrahepatic bile duct epithelial cells. Although cases of cholangiocarcinoma in the US are rare, there is a low 5-year survival rate for these patients. The preferred treatment option for all subtypes is surgical resection. Alternative options include palliative care (PC) treatments such as chemotherapy, radiotherapy and locoregional treatments. There are many obstacles in accurately diagnosing cholangiocarcinoma, including obtaining adequate tumor samples for histology and determining what is malignant vs. benign in patients with primary sclerosing cholangitis (an important risk factor of cholangiocarcinoma). Such delays in diagnosis can lead to delays in treatment, which in turn results in a poor prognosis and worse outcome for patients. To the authors’ knowledge, there is no current study assessing PC disparities in patients with cholangiocarcinoma. Methods: A total of 46,751 patients who had a diagnosis with cholangiocarcinoma were identified utilizing the National Cancer Database (NCDB) ICD-O-3 histology code 8160. The 5-year survival of PC use was analyzed via a Kaplan-Meier curve. Demographic factors (race, biological sex, income, facility type, insurance, geographic location, and Charlson-Deyo co-morbidity score) were studied in relation to the receipt of PC. Results: Approximately 15.16% of our cohort received PC (7,089/46,751). There was a statistically significant difference in the staging of those patients that received palliative care, with 52% of our cohort being stage IV (p &lt; 0.001). The sex of patients who received PC was equally distributed between men and women (51.0% to 49.0%). The majority of PC recipients were white (83.6%) individuals making under $63,000 (69.6%) with a reported Charlson-Deyo score of 0 (64.9%). Many patients who received PC had Medicare (57.6%) and were treated at either an academic/research program (45.4%) or at a comprehensive community cancer program (33.6%). Facility locations were predominantly located in the Mid-South Atlantic and East North Central regions, compared to the Pacific regions (56.3% vs 8.4%), and patients who received PC lived mainly in urban areas (98.2%). The median survival for PC patients was shorter compared to patients that did not receive PC (5.32 months vs 9.23 months). Conclusions: This is one of the most comprehensive studies that identifies the demographic disparities of patients who received PC for cholangiocarcinoma. The typical PC patient is a white individual with Medicare, living in an urban area in the Mid-South Atlantic and East North Central region making under $63,000. By highlighting the disparities that exist, our study can aid clinicians in addressing PC under-utilization in specific demographics to help provide more comprehensive care.

Sociodemographic factors associated with end-of-life palliative care utilization in female breast cancer: A national inpatient database analysis.

12035 Background: Palliative care (PC) has been shown to improve end-of-life quality in cancer patients. Nevertheless, several studies suggest that PC utilization is associated with socioeconomic factors. Patients with breast cancer, the most common neoplasm in women in the U.S., has lower PC utilization than those with other malignancies. We aim to investigate any sociodemographic barriers that are associated with the inpatient PC utilization in female breast cancer in the U.S. at the end of life. Methods: We used the National Inpatient Sample database of Healthcare Cost and Utilization Project, an all-payer inpatient care database in the United States, with data years 2014-2019. The end-of-life case was defined as hospitalized at least three days and passed away. We included all adult women (age at least 18 years old and female gender in electronic health records). The breast cancer cases were identified with International Classification of Diseases (ICD) 9th or 10th edition within the top three diagnoses. PC consultation could be identified with the ICD procedure code. Comorbidities were controlled with Charlson Comorbidity Index. After univariable analysis, the factors that were statistically associated with PC utilization would subsequently be added to the multivariable logistic regression model. Results: Between the year 2014 to 2019, we identified a total of 2,226 adult female patients who had breast cancer as their top three diagnoses and were hospitalized at least three days before death. 217 (9.7%) cases were 40-49 years old; 441 (19.8%) cases were 50-59 years old; and 1,455 (65.4%) patients were at least age 60 or above. The top three racial groups were Caucasian 1,420 (63.8%), African American 418 (18.8%), and Hispanic 166 (7.5%). 1,267 (56.9%) of all the cases had PC consult. African American (adjusted odds ratio [aOR]: 0.75; p &lt; 0.005) and Hispanic (aOR: 0.62; p &lt; 0.05) were significantly associated with less PC utilization than the Caucasian reference group in multivariable regression model. Lower PC prevalence was also observed at rural hospitals and Midwest region. Higher income group and private insurance no longer showed statistically significant higher PC utilization after adjusted for other variables. Conclusions: In end-of-life hospitalization with breast cancer as primary diagnosis, racial and hospital resource factors were significantly associated with the PC utilization. Cultural difference could be associated with the lower PC prevalence since adjusting income and insurance types could not explain the disparities in PC utilization among different racial groups. Future study should investigate and address the disparities of PC utilization in female terminal breast cancer.

Disparities in palliative care utilization and outcomes during inpatient hospitalization for gynecologic malignancies in the United States, 2009–2018

To assess palliative care (PC) utilization and outcomes in a nationally representative sample among gynecologic oncology patients who died during nonsurgical hospitalization. We hypothesized that PC would be associated with improved patient outcomes but that its availability would be limited by social determinants of health.

Disparities of Palliative Care Utilization in End-of-Life Hospitalized Patients with Leukemia: An Analysis of National Inpatient Sample Database

Background: Early palliative care (PC) encounter has been shown to improve the quality of end-of-life (EOL) care. There is a significant increased in the PC utility of leukemia patients in the past decade. We aim to investigate the use of PC service in hospitalized patients with leukemia and other malignancies at the end of their life.Methods: This is a retrospective study of National Inpatient Sample (NIS) with data year 2016-2018. The cohort of interest was adult patients (age at least 18) who had been hospitalized for at least three days and passed away. International Classification of Diseases, 10th Revision was used to identify patients with leukemia (myeloid, lymphoid and other types), other malignancies, comorbidities, PC encounters, and procedures. Primary outcome was PC encounter. PC-associated factors were analyzed with multivariate logistic regression. Statistical analysis was performed with SAS and R.Results: Among 404,011 hospitalized patients who passed away, a total of 254,431 patients stayed in the hospital for at least three days. There were 5,819 (lymphoid: 2,177; myeloid: 2,848; other: 794) and 56,270 patients had leukemia and other malignancies, respectively. 51.4% leukemia, 57.4% other malignancies and 46.2% non-cancer patients had PC encounter. The PC use significantly increased in all subgroups from 2016 to 2018 (p < 0.0001). The PC utility of leukemia patients improved from 47.4% in 2016 to 55.4% in 2018. Compared to patients with other malignancies, leukemia patients had higher portion of mechanical ventilation use and cardiopulmonary resuscitation (CPR) prior to their death (31.6% vs 40.0%, p < 0.005). The PC utility was significantly higher in other malignancies group (adjusted odds ratio [aOR]: 1.37, p < 0.0001) and lower in non-cancer group (aOR: 0.85, p < 0.0001). Advanced age, female, Medicaid, private insurance, self-pay, higher income, larger hospital size, urban hospital, Midwest and West Region year of 2017 and 2018 were also associated with increased PC utility and African American, Hispanic, Asian or Pacific Islander, South region were associated with lower odds of receiving PC (Figure 1). Among leukemia patients, myeloid leukemia group had higher odds of PC encounter than lymphoid group (aOR: 1.28, p < 0.0001). African American, Hispanic, lower income, and smaller hospital were associated with significantly lower PC consult in leukemia patients.Conclusion: There was an encouraging trend of increased PC consult between 2016 to 2018. Nevertheless, the PC utility was still lower among EOL hospitalized patients with leukemia than with other malignancies. Racial, socioeconomic, and hospital resource disparities were significant limiting factors of PC accessibility. Further systemic intervention and investigation are required to improve the disparities of PC utilization in leukemia patients. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Early palliative care is associated with less intense care in children dying with cancer in Alabama: A retrospective, single-site study.

Regional studies show that children with cancer receive medically intense end-of-life (EOL) care, but EOL care patterns, including palliative care utilization in Alabama, remain unknown. This was a retrospective study of 233 children (0-19 years) who received cancer-directed therapy at Children's of Alabama and died from 2010 through 2019. Rates and disparities in palliative care utilization and the association between palliative care and intense EOL care, death location, and hospice were examined. The median death age was 11 years; 62% were non-Hispanic White. Forty-one percent had a non-central nervous system (CNS) solid tumor. Fifty-eight percent received palliative care, and 36% received early palliative care (≥30 days before death). Children without relapsed/refractory disease were less likely to receive palliative care than those who had relapsed/refractory disease (adjusted odds ratio [aOR], 0.2; 95% confidence interval [CI], 0.1-0.7). Children with CNS tumors and hematologic malignancies were less likely to have early palliative care (aOR for CNS tumors, 0.4; 95% CI, 0.2-0.7; aOR for hematologic malignancies, 0.3; 95% CI, 0.2-0.7) than children with non-CNS solid tumors. Late palliative care (vs none) was associated with more medically intense care (aOR, 3.3; 95% CI, 1.4-7.8) and hospital death (aOR, 4.8; 95% CI, 1.9-11.6). Early palliative care (vs none) was associated with more hospice enrollment (aOR, 3.4; 95% CI, 1.5-7.6) but not medically intense care (aOR, 1.3; 95% CI, 0.6-2.9) or hospital death (aOR, 1.8; 95% CI, 0.8-3.7). Fifty-eight percent of children dying of cancer in Alabama receive palliative care, but EOL care varies with the receipt and timing (early vs late) of palliative care. Whether this variation reflects differences in child and family preferences or systemic factors (eg, hospice access) remains unknown.

Disparities in Palliative Care Utilization Among Hospitalized People With Huntington Disease: A National Cross-Sectional Study.

People with Huntington's disease (HD) often become institutionalized and more frequently die away from the home setting. The reasons behind differences in end-of-life care are poorly understood. Less than 5% of people with HD report utilization of palliative care (PC) or hospice services, regardless of the lack of curative therapies for this neurodegenerative disease. It is unknown what factors are associated with in-patient specialty PC consultation in this population and how PC might be related to discharge disposition. To determine what HD-specific (e.g., psychosis) and serious illness-specific factors (e.g., resuscitation preferences) are associated with PC encounters in people with HD and explore how PC encounters are associated with discharge disposition. We analyzed factors associated with PC consultation for people with HD using discharge data from the National Inpatient Sample and the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. An anonymized, cross-sectional, and stratified sample of 20% of United States hospitalizations from 2007 through 2014 were included using ICD-9 codes. 8521 patients with HD were admitted to the hospital. Of those, 321 (3.8%) received specialty PC. Payer type, (specifically private insurer or other insurer as compared to Medicare), income, (specifically the top quartile as compared to the bottom quartile), mortality risk, D.N.R., aspiration pneumonia, and depression were significantly associated with PC in a multivariate model. Among those who received PC, the odds ratio (OR) of discharge to a facility was 0.43 (95% CI, 0.32-0.58), whereas the OR of discharge to home with services was 2.25 (95% CI 1.57-3.23), even after adjusting for possible confounders. Among patients with HD, economic factors, depression, and serious illness-specific factors were associated with PC, and PC was associated with discharge disposition. These findings have implications for the adaptation of inpatient PC models to meet the needs of persons with HD.

Racial and ethnic disparities in palliative care utilization among gynecological cancer patients

BackgroundPalliative care (PC) is recommended for gynecological cancer patients to improve survival and quality-of-life. Our objective was to evaluate racial/ethnic disparities in PC utilization among patients with metastatic gynecologic cancer. MethodsWe used data from the 2016 National Cancer Database (NCDB) and included patients between ages 18–90 years with metastatic (stage III-IV) gynecologic cancers including, ovarian, cervical and uterine cancer who were deceased at last contact or follow-up (n = 124,729). PC was defined by NCDB as non-curative treatment, and could include surgery, radiation, chemotherapy, and pain management or any combination. We used multivariable logistic regression to evaluate racial disparities in PC use. ResultsThe study population was primarily NH-White (74%), ovarian cancer patients (74%), insured by Medicare (47%) or privately insured (36%), and had a Charlson-Deyo score of zero (77%). Over one-third of patients were treated at a comprehensive community cancer program. Overall, 7% of metastatic gynecologic deceased cancer patients based on last follow-up utilized palliative care: more specifically, 5% of ovarian, 11% of cervical, and 12% of uterine metastatic cancer patients. Palliative care utilization increased over time starting at 4% in 2004 to as high as 13% in 2015, although palliative care use decreased to 7% in 2016. Among metastatic ovarian cancer patients, NH-Black (aOR:0.87, 95% CI:0.78–0.97) and Hispanic patients (aOR:0.77, 95% CI:0.66–0.91) were less likely to utilize PC when compared to NH-White patients. Similarly, Hispanic cervical cancer patients were less likely (aOR:0.75, 95% CI:0.63–0.88) to utilize PC when compared to NH-White patients. ConclusionsPC is highly underutilized among metastatic gynecological cancer patients. Racial disparities exist in palliative care utilization among patients with metastatic gynecological cancer.

Prevalence, trend and disparities of palliative care utilization among hospitalized metastatic breast cancer patients who received critical care therapies

BackgroundEarly integration of palliative care (PC) for patients with advanced cancer has been recommended to improve quality of care. This study aims to describe prevalence, temporal trend and predictors of PC use in metastatic breast cancer (mBCa) patients receiving critical care therapies (CCT; included invasive mechanic ventilation, percutaneous endoscopic gastrostomy tube, total parenteral nutrition, tracheostomy and dialysis). MethodsThe National Inpatient Sample was queried for mBCa patients receiving CCT between 2005 and 2014. Annual percent changes (APC) were calculated for PC prevalence in the overall cohort and subgroups. Multivariable logistic analysis was used to explore predictors of PC use. ResultsOf 5833 mBCa patients receiving CCT, 880 (15.09%) received PC. Rate of PC use increased significantly from 2.53% in 2005 to 25.96% in 2014 (APC: 35.75%; p < 0.0001). Higher increase in PC use was observed in South (from 0.65% to 27.11%; APC: 59.42%; p < 0.0001), medium bedsize hospitals (from 3.75% to 26.05%; APC: 38.16%; p = 0.0006) and urban teaching hospitals (from 4.13% to 29.86%; APC: 37.33%; p = 0.0005). Multivariable analysis revealed that year interval, urban teaching hospitals, and invasive mechanical ventilation were associated with increased PC use, while primary diagnosis of gastrointestinal disorders, fractures, metastatic sites from lymph nodes and tracheostomy were associated with lower PC use. ConclusionsPC use in mBCa patients receiving CCT increases significantly over the period. However, it still remains low. Efforts to illustrate disparities in PC use are needed to improve quality of care for mBCa patients receiving CCT, especially for those hospitalized in rural and nonteaching hospitals.

Abstract TP190: Elderly Stroke Patients Seen by Telemedicine and Retained at Spoke Community Hospitals Have Lower Early Mortality and Discharge to Hospice Than Those Presenting to a University Hub Hospital

Introduction: Age remains one of the most important non-modifiable risk factors leading to poor outcomes after acute ischemic stroke (AIS). Telemedicine (TM) increases care access for elderly AIS patients especially in rural areas, yet their outcomes after initial TM consultation in the emergency department (ED) are unknown. We compared discharge disposition between elderly AIS patients who presented to and were retained at spoke community hospitals (SCHs) in our TM network versus those who presented directly to the TM hub (DTH). Methods: From both our network’s hub and TM stroke registries, we identified AIS patients ≥80 years old who presented to the ED (9/2015 - 12/2018). We compared incidence of discharge disposition to hospice or expiration (HE) as well as demographic and clinical characteristics between the SCH and DTH patients. Patients transferred after TM evaluation or who did not present directly to the hub ED were excluded. Results: Of 716 patients seen by TM, 532 were admitted to SCHs and 64 (12%) went on to HE. Out of 388 patients presenting DTH, 111 (29%) went on to HE. DTH patients were more likely to go on to HE (OR 2.93; 95% CI 2.08 - 4.12) compared to those presenting to and retained at SCHs (Figure 1a). This difference persisted when adjusting for baseline characteristics, stroke severity, and acute treatment (OR 3.01; 95% CI 1.01 - 8.96) (Figure 1b). In both study groups, increased age and severe stroke were highly associated with HE in the multivariate analysis. DTH patients with dementia had a higher odds of HE upon discharge (p=0.009) while those who received endovascular therapy had a lower odds (p=0.014). High premorbid mRS did not confer significantly higher odds of HE in either group. Conclusions: Elderly patients seen over TM and admitted to SCHs have lower early mortality and discharge disposition to hospice compared to those who present DTH. Further study is needed to elucidate whether disparities in palliative care utilization account for this difference.