End-of-life care quality for American Indians with cancer

American Indians experience disparities in cancer outcomes. Little is known about the quality of end-of-life care in American Indian patients with cancer.

We retrospectively analyzed end-of-life care for North Carolina patients who died (decedents) diagnosed with any cancer between 2003 and 2018 using the Cancer Information & Population Health Resource. Measures of end-of-life care quality were informed by existing literature and included in-hospital death, hospice use, and other health-care utilization within the last 30 days of life. Associations between race and ethnicity and end-of-life outcomes were evaluated to estimate adjusted risk ratios (RRs). Because within-group heterogeneity can influence health outcomes and intervention effectiveness, we also evaluated associations among American Indian individuals only.

We identified 163 285 (1769 American Indian and 161 516 White) decedents. The majority (60%) of American Indian individuals lived in a geographic area characterized by non-federally recognized tribes. American Indian decedents had greater proportions of rural residence than White decedents (54.5% American Indian vs 30.4% White) and dual-Medicaid/Medicare enrollment (37.4% American Indian vs 17.7% White). Compared with White decedents, American Indian decedents had increased hospital admission (adjusted RR = 1.10, 95% confidence interval [CI] = 1.06 to 1.15), intensive care unit admission (adjusted RR = 1.21, 95% CI = 1.11 to 1.32), and more than 1 emergency department visit (adjusted RR = 1.31, 95% CI = 1.20 to 1.44) in the last 30 days of life. We observed statistically significant within-group variation in end-of-life care quality among American Indian patients.

Structural barriers to care and rurality may contribute to lower-quality end-of-life care among American Indian decedents compared with White patients. High-quality, culturally appropriate end-of-life care will require a better understanding of care decision-making and access.