Site of care may affect patients' access to palliative treatment

For patients at the end of life, palliative care can prolong survival and improve the quality of life for patients with a life-threatening illness and for their families. But studies have found that racial and ethnic minorities are less likely to receive end-of-life palliative care than their counterparts. A new study conducted by investigators at Brigham and Women’s Hospital set out to understand why and has revealed that site of care may be a key contributing factor to this difference among patients with advanced, metastatic cancer. Their results are published in JAMA Network Open.

“There is a growing role for palliative care, and most physicians accept that many patients in the late stages of cancer should be referred to palliative care,” said corresponding author Quoc-Dien Trinh, MD, a physician in the Division of Urological Surgery and the Center for Surgery and Public Health (CSPH) at the Brigham.

“We knew that black and Hispanic cancer patients receive palliative care at lower rates than white patients, but until now, we didn’t know why. Was it just that doctors were not offering these services to their black and Hispanic patients? Or is there some other factor at play?” said first author Alexander P Cole, MD, also of the Division of Urological Surgery and CSPH.

In their study, Trinh, Cole and colleagues found that patients treated at some hospitals have only about two-thirds the odds of receiving palliative care compared to those receiving care at typical hospitals. These tend to be hospitals that disproportionately treat minority patients.

“We find that the site of care seems to be a key determinant of whether or not someone receives palliative care,” said Trinh.

The team conducted a retrospective, registry-based analysis of adults diagnosed with four types of metastatic cancer using data from the Participant Use Files of the National Cancer Database (NCDB). The team focused on men and women 40 years and older with metastatic prostate, non-small cell lung, colon and breast cancer–four common and lethal cancers. The main outcome measured was receipt of palliative care, such as pain control, surgical treatment, radiation therapy and systemic chemotherapy administered to alleviate symptoms but not to cure disease.

Investigators looked at the hospitals at which patients received care, calculating the proportion of minority patients (black or Hispanic) treated at each. Hospitals with the greatest proportion of minorities were considered “minority serving hospitals” (MSH). Hospitals that were not in the top 10 percent were considered “non-minority serving hospitals” (non-MSH).

The team found that of the more than 600,000 individuals with metastatic cancer studied, 21.7 percent received palliative care. Overall, 22.5 percent of white patients (106,603 people) received palliative care, while only 20.0 percent of black patients (16,435 people) and 15.9 percent of Hispanic patients (3,551) received palliative care. After adjusting for other variables, the team found that patients who received care at an MSH had two-thirds the odds of receiving palliative care compared with those who received care at a non-MSH, regardless of the patient’s race or ethnicity.

“Our mission is to reduce inequity in health care, and the first step in doing so is to raise awareness of these disparities,” said Trinh. “These findings suggest that there are significant racial and ethnic disparities in receipt of palliative care for patients with metastatic cancer and that these disparities are largely accounted for by the site of a patient’s care. Strategies that focus on improving palliative care use at minority-serving hospitals may be an effective strategy to increase the receipt of palliative care for minorities.”

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Funding for this work was provided by the Brigham Research Institute Fund to Sustain Research Excellence.

Paper cited: Cole, AP 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 Network Open DOI: 10.1001/jamanetworkopen.2018.7633