End-of-life care for people with likely terminal cancer can be quite variable, and may have indicators of poor care quality as well as running up health spending. A new study attempts to identify reasons for variation and the extent to which it is linked with multiple morbidity. (J. Geriatric Oncology Article) The authors used data from 1991 to 2008 from surveys and Medicare fee-for-service claims to identify patients who had terminal cancer and multiple chronic diseases and functional limitations. They studied use of hospice, death in hospital, use of hospital or ER in the last month of life, and use of aggressive cancer treatment. About 60% of all the patients in the study had a combination of chronic conditions, functional limitations and geriatric syndromes. Older patients were less likely to receive cancer treatment near the end-of-life. People with higher education and income were more likely to receive such treatment. There were no significant differences in race or ethnicity. Admission to a hospital or an ER was lower in older patients, but higher among African-Americans and use of hospice was lower among that group. Therefor, African-Americans were more likely to die in the hospital. Income and education had a U-shaped association with in-hospital death. Age and marital sex were not associated strongly with any of the outcomes. High morbidity was not associated with any outcome, but more functional limitations and presence of geriatric syndrome made it less likely that cancer treatment would be received. From this study, it would appear that there generally are not strong associations with many social determinants and end-of-life care, nor with many general health status issues. This suggests that using these factors as a basis for intervention to ensure more rational use of end-of-life care will be difficult.
