Racial Disparities in Hospice Enrollment Persist in Ovarian Cancer

Though many elderly patients with ovarian cancer enroll in hospice care, a substantial proportion subsequently unenroll and die without hospice, according to a new study. Black patients are more likely to unenroll than white patients.

“Acceptance of hospice care is increasing on a national level, including among patients with ovarian cancer, the deadliest gynecologic malignancy,” wrote study authors led by Jolyn S. Taylor, MD, MPH, of the University of Texas MD Anderson Cancer Center in Houston. “However, disparities still exist among ovarian cancer patients with regard to hospice usage and receiving invasive end-of-life care.”

Previous research has shown that minority patients as well as those of lower socioeconomic status have less hospice use and more aggressive end-of-life care; the researchers aimed to further characterize differences in hospice use in a cohort of 2,331 ovarian cancer patients who died between 2005 and 2012 after more than 12 months of continuous Medicare coverage before death. The results were published in Gynecologic Oncology.

Of the full cohort, 77% of patients were white, 15% were Hispanic, and 7% were black (1% other). Most of the cohort were from urban settings (79%). A total of 1,756 patients (75%) enrolled in hospice prior to death, though only 1,580 patients (68%) died while enrolled. A total of 176 patients (10% of those who enrolled in hospice) unenrolled from hospice prior to death and died while not in hospice. A total of 346 patients unenrolled from hospice multiple times; the median duration of enrollment was 18 days for all patients, and 23 days for those who unenrolled from hospice.

Compared with patients who died in 2005, those who died in the later years of the study (2009–2012) were less likely to unenroll from hospice before death. For example, those who died in 2011 had an odds ratio (OR) for unenrolling of 0.15 (95% CI, 0.06–0.35; P < .0001).

Racial disparities with regard to the odds of unenrolling were also observed. Compared with non-Hispanic white patients, non-Hispanic black patients had an OR for unenrolling from hospice prior to death of 2.07 (95% CI, 1.15–3.73; P = .02). There was no difference between Hispanic patients and non-Hispanic white patients.

There were no differences with regard to ethnicity and the likelihood of enrolling and unenrolling in hospice multiple times. The factors that were significantly associated with multiple unenrollments included a longer duration from diagnosis to death, and an age of more than 80 years.

Among the 176 patients who unenrolled and died outside of hospice care, 30% received at least one life-extending or invasive procedure, or required multiple emergency room visits or an ICU admission following unenrollment. A further analysis showed that enrollment in hospice was associated with lower costs paid by Medicare during the last year, 6 months, and 30 days of life, compared with those who never enrolled in hospice. The differences between those who stayed enrolled and those who unenrolled at any point were not significant, with the exception of the last 6 months of life.

“While there is inherent difficulty in assessing outcomes posthumously, these data suggest a conflict in ideology between hospice and avoidance of invasive and intensive care near the end of life and unenrolling from hospice in order to receive such invasive procedures,” the authors wrote. “An important area of future research is the exploration of patterns of events that lead to patients enrolled in hospice choosing to undergo invasive or intensive care and if these scenarios can or should be avoided.”

Thomas J. Smith, MD, of Johns Hopkins School of Medicine in Baltimore, who was not involved with the research, told Cancer Network that the racial disparities seen in this study confirm those observed in previous research. "What we really need to know are the following: Why did people disenroll? Is it because they had fewer resources to take care of people as they sickened, such as being unable to afford additional paracentesis for ascites if hospice does not cover procedures? Or something else?," he said. "Until we know these answers, we should still be utilizing hospice for all our patients near the end of life, regardless if they will disenroll."