Evaluation of End-of-Life Quality Care Between American Indian and White North Carolina Decedents Diagnosed With Lung Cancer, 2003-2020.

Purpose: Lung cancer mortality rates for American Indians (AIs) are the highest among US race groups. End-of-life (EOL) care presents opportunities to limit aggressive and potentially unnecessary treatment. We evaluated differences in EOL quality of care between AI and White (WH) decedents with lung cancer.

Methods: Our cohort included adult AI and WH decedents diagnosed with lung cancer (2003-2020) in North Carolina, who had health insurance claims during the month of and the month preceding death. EOL outcomes assessed during the last 30 days of life included intravenous chemotherapy, hospital admission, hospice initiation, ICU admission, >one emergency department (ED) visit, and in-hospital death. We used Poisson regression models to estimate risk ratios (RRs) and 95% CLs for each outcome comparing AI with WH, adjusting for rural/urban residence, age at diagnosis, insurance status, sex, histology, and diagnosis year. We also evaluated associations in the metastatic lung cancer subcohort.

Results: Our cohort comprised 594 AI and 49,296 WH decedents. Compared with WH decedents, AIs were younger at diagnosis (66 v 71 years), more frequently Medicaid-insured (24% v 11%), and more frequently rural residents (51% v 30%). During the last 30 days of life, compared with WH decedents, AIs had higher risks of hospital admissions (RR, 1.14 [1.07-1.22]), ICU admissions (RR, 1.24 [1.08-1.42]), >one ED visits (RR, 1.27 [1.09-1.47]), and in-hospital death (RR, 1.22 [1.06-1.40]).

Conclusion: Indicators of inappropriate EOL care (hospital, ICU, and ED admissions) were notably higher during the last month of life for AI decedents with lung cancer. These findings highlight EOL care as an area where more interventions are needed to improve AI cancer care.