End-of-life care quality for American Indians with cancer.

Abstract

Background: American Indians experience disparities in cancer outcomes. Little is known about the quality of end-of-life care in American Indian patients with cancer.

Methods: We retrospectively analyzed end-of-life care for North Carolina patients who died (decedents) diagnosed with any cancer between 2003 and 2018 using the Cancer Information & Population Health Resource. Measures of end-of-life care quality were informed by existing literature and included in-hospital death, hospice use, and other health-care utilization within the last 30 days of life. Associations between race and ethnicity and end-of-life outcomes were evaluated to estimate adjusted risk ratios (RRs). Because within-group heterogeneity can influence health outcomes and intervention effectiveness, we also evaluated associations among American Indian individuals only.

Results: We identified 163 285 (1769 American Indian and 161 516 White) decedents. The majority (60%) of American Indian individuals lived in a geographic area characterized by non-federally recognized tribes. American Indian decedents had greater proportions of rural residence than White decedents (54.5% American Indian vs 30.4% White) and dual-Medicaid/Medicare enrollment (37.4% American Indian vs 17.7% White). Compared with White decedents, American Indian decedents had increased hospital admission (adjusted RR = 1.10, 95% confidence interval [CI] = 1.06 to 1.15), intensive care unit admission (adjusted RR = 1.21, 95% CI = 1.11 to 1.32), and more than 1 emergency department visit (adjusted RR = 1.31, 95% CI = 1.20 to 1.44) in the last 30 days of life. We observed statistically significant within-group variation in end-of-life care quality among American Indian patients.

Conclusions: Structural barriers to care and rurality may contribute to lower-quality end-of-life care among American Indian decedents compared with White patients. High-quality, culturally appropriate end-of-life care will require a better understanding of care decision-making and access.