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Disparities in hospice care among older women dying with ovarian cancer,☆☆

https://doi.org/10.1016/j.ygyno.2011.11.041Get rights and content

Abstract

Background

Timely hospice referral is an essential component of quality end-of-life care, although a growing body of research suggests that for patients with various types of cancer, hospice referrals often occur very late in the course of care, and are marked by sociodemographic disparities. However, little is known about the ovarian cancer patient population specifically. We examined the extent and timing of hospice referrals in ovarian cancer patients over age 65, and the factors associated with these outcomes.

Methods

We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify 8211 women aged 66 + with ovarian cancer who were diagnosed between 2001 and 2005 and died by December 31, 2007. We excluded women who were not eligible for Medicare A continuously during the 6 months prior to death. Outcomes studied included overall hospice use in the last 6 months of life and late hospice enrollment, defined as within 3 days of death. We examined variations in these two measures based on year of diagnosis and sociodemographic characteristics (age, race, marital status, rural residence, income, education) and type of Medicare received (fee-for-service vs. managed care).

Results

Among 8211 women in the cohort who died from ovarian cancer, 39.7% never received hospice care (3257/8211). Overall hospice care increased over the period of observation, from 49.7% in 2001 to 74.9% in 2005, but the proportion of women receiving hospice care within 3 days of death did not improve. Among those who received hospice care, 11.2% (556/4954) and 26.2% (1299/4954) received such care within 3 and 7 days of death, respectively. A higher proportion of black women (46.5% vs. 38.4% among whites), women in the lowest income group (42.8% vs. 37.0% in the highest income group), and those receiving fee-for-service Medicare (41.3% vs.33.5% for women in managed care) never received hospice care. In multivariable models, factors associated with lack of hospice care included age younger than 80 years (OR 1.27, 95% CI 1.15–1.40), non-white race (OR 1.44, 95% CI 1.26–1.65), low income (OR 1.17, 95% CI 1.04–1.32) and enrollment in fee-for-service Medicare compared with managed care (OR 1.39, 95% CI 1.24–1.56).

Conclusion

More older women with ovarian cancer are receiving hospice care over time, however, a substantial proportion receive such care very near death, and sociodemographic disparities in hospice care exist. Our data also support the need to target lower-income and minority women in efforts to increase optimally timed hospice referrals in this population. Our finding that ovarian cancer patients enrolled in managed care plans were more likely to receive hospice care suggests the importance of health care system factors in the utilization of hospice services.

Highlights

► We examined hospice use and timing among older women with ovarian cancer in the SEER-Medicare dataset. ► More ovarian cancer patients are receiving hospice care, yet many are referred three or fewer days before death. ► Advanced age, nonwhite race, low income group, and being in fee-for-service Medicare are associated with less hospice use.

Introduction

Advanced ovarian cancer in elderly women is a disease with a poor prognosis. In the United States, from 2000 to 2007, women aged 65 and older accounted for 46% of ovarian cancers with an incidence rate per 100,000 that was 7 times higher (28.8) than for women under age 65 (4.4). Among elderly women with ovarian cancer, 72% were diagnosed with distant disease. Two-year cause-specific survival for elderly women with advanced ovarian cancer is 40.8% [1].

For patients with diseases such as advanced cancer, high quality end-of-life (EOL) care should focus on alleviating symptoms and respecting patient preferences for intensity of health care and place of death. Many elderly patients report preferring a focus on palliation at the end of life, rather than extending life [2]. There has been considerable effort in defining and validating measures of high quality EOL care for cancer patients. Specific quality measures for EOL cancer care proposed by Earle and others [3] include: short interval between last chemotherapy date and death, short interval between starting a new chemotherapy regimen and death, high proportion of deaths in hospital versus home, frequent emergency room visits, high number of hospital and ICU days near EOL, low proportion of patients enrolled in hospice, and hospice enrollment within 3 days of death. These measures were selected based on existing literature, patient and family focus groups, and an expert panel using a modified Delphi approach. Proposed benchmarks for EOL cancer care using claims data have also been described based on similar measures using Medicare claims [4]. These measures have been validated and used in studies demonstrating that EOL cancer care is often characterized by unwanted and overly aggressive interventions including chemotherapy within 14 days of death, no hospice referral, and hospice admission only within 3 days of death [5].

Hospice is a model of end-of-life care that focuses on symptom palliation and patient autonomy [6]. Hospice care in general is associated with better pain and symptom control, regardless of diagnosis [7]. Timely hospice referral is beneficial to patients by avoiding unduly aggressive late-life interventions (such as hospital and ICU admissions) and improving symptom palliation [8], [9]. Appropriate use of hospice care across the cancer population may help improve quality of care at EOL for individual patients, but also may be beneficial to society by avoiding inappropriate resource use.

Variation and disparities in hospice use and timing have been explored in a number of settings [10]. Considerable variation of duration of hospice care has been reported, (even among various cancer diagnoses) [9]. However, little work has been done to describe patterns of hospice care utilization in patients with ovarian cancer.

We therefore sought to describe enrollment, timing, and disparities in hospice care for older women with ovarian cancer in this Medicare population. We also examined whether hospice use had changed over time for older patients with ovarian cancer, an important malignancy affecting women.

Section snippets

Data sources

Data for this analysis came from the linkage of the Surveillance, Epidemiology, and End Results (SEER) registries with health care claims reported to Medicare. The population-based registries participating in the SEER program represent defined geographic areas and have changed over time. The registries included in our analysis range from 14% of the US population (1998–2000) to 26% of the US population (2001–2005) [11]. An estimated 97% of incident cancer cases are captured by cancer registrars

Results

Our cohort included a large number of aged women, with 41.0% of the sample aged 80 or older (Table 1). A large percentage of cases were diagnosed with advanced disease, 72.6% had Stage III or IV cancer. The majority of patients (87.1%) were white, and 78.6% were enrolled in fee-for-service Medicare.

Overall, 39.7% of our cohort did not receive hospice care during the 6 months before death (3257/8211). A higher proportion of black women did not receive hospice care (46.5% vs. 38.4% among whites).

Discussion

Our findings reveal a mixed picture of hospice use among elderly women with ovarian cancer. We observed rising use of hospice services over time between 2001 and 2005, with three-quarters of all older ovarian cancer patients receiving hospice. However, we found that the use of hospice care varied by race and socio-economic status. These findings are consistent with earlier studies reporting lower hospice use for blacks, Asians, and Hispanics among Medicare recipients with other advanced stage

Conflict of interest statement

None of the authors have conflicts of interest to declare, and all have completed the Conflict of Interest Form for Gynecologic Oncology.

Acknowledgment

This study used the linked SEER-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the Applied Research Program, NCI; the Office of Research, Development and Information, CMS; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-Medicare database.

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  • Cited by (0)

    Preliminary findings from this work were reported in a podium presentation at the May 2011 Society of General Internal Medicine Meeting in Phoenix, AZ.

    ☆☆

    Supported by Research funding from Maine Medical Center's RSP Grant Program (to Dr. Fairfield). The funder had no role in the conduct of this research or preparation of the article.

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