Data Suggest Site of Facility Plays Significant Role in Racial Differences in Quality of Care

A recent retrospective cohort study found that site of care may be a significant factor associated with racial and ethnic differences in the receipt of palliative care, according to results published inJAMA Network Open.¹

In terms of race, 22.5% of patients in the analysis who identified as non-Hispanic white received palliative care versus 20% of black patients and 15.9% of Hispanic patients (P <.001). After adjusting for site of care and covariates, the difference between white and black patients was no longer statistically significant (OR, 1.02; 95% CI, 0.99-1.04). Furthermore, Hispanic patients were more likely to receive palliative care compared with white patients when considering the same variables (OR, 1.06; 95% CI, 1.01-1.10).

&ldquo;If you look at non-Hispanic white patients treated at minority-serving hospitals [MSHs], their adjusted odds of receiving palliative care were not significantly different [from] black patients at these hospitals,&rdquo; said lead investigator Alexander P. Cole, MD, in an interview withTargeted Therapies in Oncology. &ldquo;Conversely, for black patients at non-MSHs, [the] adjusted odds of receiving palliative care were similar to white patients.&rdquo;

The site of care was the facility reporting the patient case to the National Cancer Database, from which the study data were abstracted, and was defined as either an MSH or a non-MSH. MSHs were determined first by defining the proportion of minority patients (black or Hispanic); the hospitals in the top decile were considered MSHs.

The main outcome measure was any receipt of palliative care, including pain control and symptom relief, in which the goal of treatment was explicitly mentioned in the medical records. For instance, pain control following a routine surgical procedure was not considered palliative. Baseline sociodemographic covariates included age at and year of diagnosis, sex, and ethnicity. Variables such as insurance carrier, education level, and household income also were included.

The study cohort consisted of 601,680 men and women &ge;40 years with 4 main cancer types—metastatic prostate, non—small cell lung, colon, and breast&mdash;over a 12-year period. In total, 21.7% of patients received palliative care for their disease, with all patients treated at MSHs least likely to receive it, regardless of ethnicity. Based on an adjusted logistic regression model, patients who received their care at MSHs had two-thirds the odds of receiving palliative care compared with those who received care at non- MSHs (OR, 0.67; 95% CI, 0.53-0.84).

&ldquo;The data seem to be showing us that it really comes down to differences in care at different hospitals,&rdquo; said Cole, a resident in the Division of Urological Surgery at Brigham and Women&rsquo;s Hospital and Harvard Medical School in Boston, Massachusetts. &ldquo;Because 90% of minorities receive care at about 20% of hospitals, this means that we can make a huge difference by focusing on these hospitals that are not [delivering] as much palliative care.&rdquo;

Factors that increased a patient&rsquo;s likelihood of receiving care were treatment in a later study year and insurance status; patients insured by Medicaid or uninsured were most likely to receive palliative care. Study investigators hypothesized that this could be due to the absence of a strong fee-for-service incentive; additionally, patients in this population may have initial clinical presen- tation at a later stage of disease, when palliative care is the only option.

Further analysis focused on the association between cancer type and MSH status with the receipt of palliative care. Odds of receiving palliative care at MSHs compared with non-MSHs were 33% lower in the prostate cancer subgroup (OR, 0.67; 95% CI, 0.55-0.82), 27% lower in both lung cancer (OR, 0.73; 95% CI, 0.57-0.93) and breast cancer (OR, 0.73; 95% CI, 0.59-0.89), and not significantly lower in colon cancer (OR, 0.86; 95% CI, 0.67-1.09). As in the overall cohort, adjustments for MSH status offset the association between race and ethnicity and the odds of receiving palliative care.

These data suggest that the site of care may be a significant factor associated with observed differences in palliative care in racial and ethnic minorities in the United States. This is especially important because care for minorities is concentrated in a small number of hospitals, and addressing just these facilities may help improve access to care. Supporting these findings are previous study results that found that MSHs had higher readmission rates and worse performance in nononcologic clinical scenarios, as well as high inpatient mortality rates and poorer outcomes from emergency general sur- gery.^2,3Systemic differences, such as experience of hospital chairpersons, may also contribute to quality of care at MSHs.

&ldquo;The next steps are really 2-fold. First, we need to drill down on the specific hospital characteristics [that] are associated with these differences,&rdquo; Cole said.

The second step involves partnering with important stakeholders. &ldquo;Here in Massachusetts, we are working with the Department of Public Health to identify and address where these disparities are occurring in the health system at the [regional, county, and hospital level] and think holistically about interventions to help us deliver better care in these lower-performing areas,&rdquo; he said.

References:

1. Cole AP, Nguyen D-D, Meirkhanov A, et al. Association of care at minority-serving vs non-minority-serving hospitals with use of palliative care among racial/ethnic minorities with metastatic cancer in the United States. JAMA Netw Open. 2019;2(2):e187633. doi: 10.1001/ jamanetworkopen.2018.7633.
2. Jha AK, Orav EJ, Li Z, Epstein AM. Concentration and quality of hospitals that care for elderly black patients [erratum in Arch Intern Med. 2007;167(14):1532]. Arch Intern Med. 2007;167(11):1177-1182. doi: 10.1001/archinte.167.11.1177.
3. Zogg CK, Jiang W, Chaudhary MA, et al. Racial disparities in emergen- cy general surgery: do differences in outcomes persist among universally insured military patients? J Trauma Acute Care Surg. 2016;80(5):764-775. doi: 10.1097/TA.0000000000001004.