Differences by race in systemic oncologic end-of-life (EOL) care among patients with cancer.

137 Background: Prior studies indicate that Black patients with cancer are more likely to receive aggressive EOL care, including chemotherapy within 14 days (d) prior to death. However, most studies are limited to specific subgroups, and it is unclear if disparities remain in the immunotherapy era. In this study, we evaluated racial differences in systemic oncologic EOL treatment among a national all-payer cohort of patients treated in routine practice. Methods: We conducted a retrospective cohort study utilizing data from the nationwide Flatiron Health electronic health record (EHR)-derived de-identified database. Patients with confirmed cancer diagnosis, with documented treatment on or after 1/1/2011 and who died between 2015 and 2019, were included. Patients with documented race of White or Black or African American were included. We defined our outcome measures as receipt of any systemic oncologic treatment within 30d or 14d prior to death, and also stratified by mono-chemotherapy (Chemo) and immunotherapy ± targeted therapy (ICI). We used mixed-level logistic regression models to assess the likelihood of receiving each treatment, compared to patients without any EOL treatment, between Black and White patients, adjusted for patient- and practice-level characteristics as fixed effects and a practice-specific random intercept. Race-specific adjusted rates were estimated using stratified analysis. Results: A total of 40,675 White and 5,150 Black patients were included in the analysis. Compared to White patients, Black patients were younger at diagnosis, were more likely to be female and have Medicaid coverage. Black patients were more likely to be treated at practices with higher patient-to-physician ratio (25.8% in highest quintile vs. 18.7%) and with a high proportion (> 10%) of patients with Medicaid (38.1% vs. 31.6%). Compared to White patients within the same practice, Black patients were less likely to receive any EOL treatment within 30d (adjusted odds ratio [aOR]: 0.87; 95% CI: 0.81-0.93) or 14d (aOR: 0.87; 95% CI: 0.80-0.96). Adjusted rates of any EOL treatment within 30d prior to death were 33.8% and 37.6% among Black and White patients, respectively. When stratified by treatment types, Black patients were less likely to receive ICI within 30d prior to death, compared to White patients (aOR: 0.87; 95% CI: 0.76-1.00). Conclusions: Our findings differ from prior studies of oncologic EOL care and suggest that in contemporary practice Black patients are less likely to receive anti-cancer therapy near EOL, largely driven by lower rates of ICI use. Future research should investigate the complex causal pathway underlying observed racial differences among patient and practice-level factors.

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Racial Differences in Predictors of Intensive End-of-Life Care in Patients With Advanced Cancer

Journal of Clinical Oncology ◽

10.1200/jco.2009.22.4733 ◽

2009 ◽

Vol 27 (33) ◽

pp. 5559-5564 ◽

Cited By ~ 118

Author(s):

Elizabeth Trice Loggers ◽

Paul K. Maciejewski ◽

Elizabeth Paulk ◽

Susan DeSanto-Madeya ◽

Matthew Nilsson ◽

...

Keyword(s):

End Of Life ◽

Racial Differences ◽

Advanced Cancer ◽

Do Not Resuscitate ◽

Advanced Cancer Patients ◽

Black Patients ◽

Patient Reported ◽

Eol Care ◽

To Receive ◽

White Patients

Purpose Black patients are more likely than white patients to receive life-prolonging care near death. This study examined predictors of intensive end-of-life (EOL) care for black and white advanced cancer patients. Patients and Methods Three hundred two self-reported black (n = 68) and white (n = 234) patients with stage IV cancer and caregivers participated in a US multisite, prospective, interview-based cohort study from September 2002 to August 2008. Participants were observed until death, a median of 116 days from baseline. Patient-reported baseline predictors included EOL care preference, physician trust, EOL discussion, completion of a Do Not Resuscitate (DNR) order, and religious coping. Caregiver postmortem interviews provided information regarding EOL care received. Intensive EOL care was defined as resuscitation and/or ventilation followed by death in an intensive care unit. Results Although black patients were three times more likely than white patients to receive intensive EOL care (adjusted odds ratio [aOR] = 3.04, P = .037), white patients with a preference for this care were approximately three times more likely to receive it (aOR = 13.20, P = .008) than black patients with the same preference (aOR = 4.46, P = .058). White patients who reported an EOL discussion or DNR order did not receive intensive EOL care; similar reports were not protective for black patients (aOR = 0.53, P = .460; and aOR = 0.65, P = .618, respectively). Conclusion White patients with advanced cancer are more likely than black patients with advanced cancer to receive the EOL care they initially prefer. EOL discussions and DNR orders are not associated with care for black patients, highlighting a need to improve communication between black patients and their clinicians.

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Racial Differences in Pain Treatment and Empathy in a Canadian Sample

Pain Research and Management ◽

10.1155/2012/803474 ◽

2012 ◽

Vol 17 (6) ◽

pp. 381-384 ◽

Cited By ~ 28

Author(s):

Kimberley A Kaseweter ◽

Brian B Drwecki ◽

Kenneth M Prkachin

Keyword(s):

Racial Differences ◽

Facial Expressions ◽

Undergraduate Students ◽

Pain Treatment ◽

Black And White ◽

Racial Biases ◽

Patient Race ◽

Black Patients ◽

Treatment Bias ◽

White Patients

BACKGROUND: Evidence of inadequate pain treatment as a result of patient race has been extensively documented, yet remains poorly understood. Previous research has indicated that nonwhite patients are significantly more likely to be undertreated for pain.OBJECTIVE: To determine whether previous findings of racial biases in pain treatment recommendations and empathy are generalizable to a sample of Canadian observers and, if so, to determine whether empathy biases mediate the pain treatment disparity.METHODS: Fifty Canadian undergraduate students (24 men and 26 women) watched videos of black and white patients exhibiting facial expressions of pain. Participants provided pain treatment decisions and reported their feelings of empathy for each patient.RESULTS: Participants demonstrated both a prowhite treatment bias and a prowhite empathy bias, reporting more empathy for white patients than black patients and prescribing more pain treatment for white patients than black patients. Empathy was found to mediate the effect of race on pain treatment.CONCLUSIONS: The results of the present study closely replicate those from a previous study of American observers, providing evidence that a prowhite bias is not a peculiar feature of the American population. These results also add support to the claim that empathy plays a crucial role in racial pain treatment disparity.

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Cancer- Associated Venous Thromboembolism (VTE) Characteristics in Blacks Compared to Whites in Durham County, North Carolina

Blood ◽

10.1182/blood-2019-132034 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 3652-3652

Author(s):

Ibrahim Saber ◽

Maragatha Kuchibhatla ◽

Alys Adamski ◽

Lisa C. Richardson ◽

Nimia Reyes ◽

...

Keyword(s):

North Carolina ◽

Venous Thromboembolism ◽

Hematologic Malignancies ◽

The United States ◽

University Hospital ◽

Black And White ◽

Patients With Cancer ◽

Black Patients ◽

Active Cancer ◽

White Patients

Introduction: Venous thromboembolism (VTE), defined as deep vein thrombosis (DVT), pulmonary embolism (PE), or both, represents a major cause of morbidity and mortality in patients with cancer. VTE is the second leading cause of death in patients with cancer, after cancer itself, in the United States. Previous studies have suggested differences by race in the occurrence of VTE among cancer patients. The purpose of this study was to investigate clinical differences in black and white patients with VTE and cancer. Methods: We conducted an analysis of a CDC/Duke VTE surveillance project at the three hospitals in Durham County, North Carolina (Duke University Hospital, Duke Regional Hospital and the Durham VA Medical Center) from April 2012 through March 2014. A combination of electronic and manual review methods were used to identify unique Durham County residents with new diagnoses of objectively confirmed VTE. Data abstracted included demographics, risk factors including cancer, clinical data, treatment, and outcomes. Results: A total of 1028 patients with a new VTE were identified during the surveillance period. Twenty-seven patients who were not black or white (e.g., race not listed; Asian; etc), and 41 with VTE affecting areas other than PE or limb DVT (e.g., cerebral sinus venous thrombosis) were excluded from this analysis. Of the remaining 960 patients, slightly more than half were female (497/960=51.8%), more than half were black (508/960=52.9%), almost a third were obese (337/960 = 35.1%), and median age was 59 years old. At the time of their VTE diagnosis, 184 patients with VTE (19.2%) had active cancer, defined as metastatic or diagnosed within the previous 6 months. The proportion of VTE associated with cancer varied by race. Among the 508 black patients with VTE, 111 (21.9%) had active cancer; in comparison, among the 452 white patients with VTE, 73 (16.1%) had active cancer (p-value=0.025). Black patients with VTE and cancer were older, had a lower body mass index (BMI), and were less likely to have sustained a prior VTE compared to black patients with VTE who did not have cancer (Table 1). Similarly, white patients with VTE and cancer had a lower BMI than white patients without cancer (Table 1). However, in contrast to the findings for black patients, white patients with VTE and cancer were not significantly older and did not show differences in having a prior VTE than white patients with VTE who did not have cancer. Additionally, white patients with VTE and cancer were much more likely to have sustained a PE, with or without DVT, and less likely to have sustained a DVT alone, than white patients with VTE who did not have cancer (Table 1). Black and white patients with both VTE and cancer, were similar in several aspects; however, white patients were less likely to have sustained a DVT alone and more likely to have sustained a PE, with or without DVT, compared to black patients. The types of cancer most frequently encountered in black patients with VTE were gastrointestinal (24.3%), genitourinary (23.4%), and lung (18.9%), followed by breast (8.1%), gynecologic (9.0%) and hematologic malignancies (9.9%). The types of cancer most frequently encountered in white patients with VTE were lung (27.4%), breast (16.4%), and gastrointestinal (13.7%), followed by genitourinary (9.6%), gynecologic (8.2%) and hematologic malignancies (6.8%). Black and white patients with VTE and cancer were treated similarly to black and white patients with VTE who did not have cancer, with most receiving anticoagulant therapy and fewer than 10% receiving an IVC filter (Table 1). Enoxaparin was used most frequently, followed by warfarin. Conclusions: There are several notable demographic and clinical differences between patients with VTE with and without cancer. While differences were observed for both black and white patients, several factors that were variable according to cancer status were unique to either black patients or white patients. One notable difference between black and white patients with both VTE and cancer was a lower proportion of DVT only and a higher proportion of PE, with or without DVT, in white patients. Disclosures Ortel: Instrumentation Laboratories: Consultancy.

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Racial Disparities in End-of-Life Communication and Preferences among Chronic Kidney Disease Patients

American Journal of Nephrology ◽

10.1159/000447097 ◽

2016 ◽

Vol 44 (1) ◽

pp. 46-53 ◽

Cited By ~ 22

Author(s):

Nwamaka D. Eneanya ◽

Julia B. Wenger ◽

Katherine Waite ◽

Stanley Crittenden ◽

Derya B. Hazar ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

End Of Life ◽

Cultural Beliefs ◽

Stage Iv ◽

Cross Sectional ◽

Black And White ◽

Black Patients ◽

Eol Care ◽

White Patients

Background: Previous studies on end-of-life (EOL) care among patients with chronic kidney disease (CKD) have been largely limited to White hemodialysis patients. In this study, we sought to explore racial variability in EOL communication, care preferences and advance care planning (ACP) among patients with advanced CKD prior to decisions regarding the initiation of dialysis. Methods: We performed a cross-sectional study between 2013 and 2015 of Black and White patients with stage IV or V CKD (per the Modified Diet in Renal Disease estimation of GFR <30 ml/min/1.73 m2) from 2 academic centers in Boston. We assessed experiences with EOL communication, ACP, EOL care preferences, hospice knowledge, spiritual/religious and cultural beliefs, and distrust of providers. Results: Among 152 participants, 41% were Black. Black patients were younger, had less education, and lower income than White patients (all p < 0.01). Black patients also had less knowledge of hospice compared to White patients (17 vs. 61%, p < 0.01). A small fraction of patients (8%) reported having EOL discussions with their nephrologists and the majority had no advance directives. In multivariable analyses, Blacks were more likely to have not communicated EOL preferences (adjusted OR 2.70, 95% CI 1.08-6.76) and more likely to prefer life-extending treatments (adjusted OR 3.06, 95% CI 1.23-7.60) versus Whites. Conclusions: As Black and White patients with advanced CKD differ in areas of EOL communication, preferences, and hospice knowledge, future efforts should aim to improve patient understanding and promote informed decision-making.

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Distributed Counterfactual Modeling Approach for Investigating Hospital-Associated Racial Disparities in COVID-19 Mortality

10.1101/2021.09.14.21263596 ◽

2021 ◽

Author(s):

Mackenzie J Edmondson ◽

Chongliang Luo ◽

Nazmul Islam ◽

David Asch ◽

Jiang J Bian ◽

...

Keyword(s):

Racial Differences ◽

Hospital System ◽

Black And White ◽

Patient Level ◽

Modeling Approach ◽

Black Patients ◽

The Difference ◽

Using Data ◽

The Impact ◽

White Patients

Several studies have found that black patients are more likely than white patients to test positive for or be hospitalized with COVID-19, but many of these same studies have found no difference in in-hospital mortality. These studies may have underestimated racial differences due to reliance on data from a single hospital system, as adequate control of patient-level characteristics requires aggregation of highly granular data from several institutions. Further, one factor thought to contribute to disparities in health outcomes by race is site of care. Several differences between black and white patient populations, such as access to care and referral patterns among clinicians, can lead to patients of different races largely attending different hospitals. We sought to develop a method that could study the potential association between attending hospital and racial disparity in mortality for COVID-19 patients without requiring patient-level data sharing among collaborating institutions. We propose a novel application of a distributed algorithm for generalized linear mixed modeling (GLMM) to perform counterfactual modeling and investigate the role of hospital in differences in COVID-19 mortality by race. Our counterfactual modeling approach uses simulation to randomly assign black patients to hospitals in the same distribution as those attended by white patients, quantifying the difference between observed mortality rates and simulated mortality risk following random hospital assignment. To illustrate our method, we perform a proof-of-concept analysis using data from four hospitals within the OneFlorida Clinical Research Consortium. Our approach can be used by investigators from several institutions to study the impact of admitting hospital on COVID-19 mortality, a critical step in addressing systemic racism in modern healthcare.

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Measuring disparities in quality of oncology care across oncology practices.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.6533 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. 6533-6533

Author(s):

Nancy Lynn Keating ◽

Mary Beth Landrum ◽

Alan Zaslavsky ◽

Cleo A. Samuel ◽

Anna Sinaiko ◽

...

Keyword(s):

Racial Disparities ◽

Quality Measures ◽

Care Quality ◽

Fee For Service ◽

Practice Level ◽

Black And White ◽

Percentage Points ◽

Black Patients ◽

Ed Visits ◽

White Patients

6533 Background: Equity is now recognized as an essential aspect of health care quality. Racial inequities in clinical performance diminish overall system performance. We assessed the feasibility and reliability of practice-level measures of racial disparities in chemotherapy-associated emergency department (ED) visits and hospitalizations. Methods: Using fee-for-service Medicare data, we identified 1,196,970 Black or White fee-for-service Medicare beneficiaries with cancer receiving chemotherapy in 2016-2019, who were attributed to 5511 oncology practices that treated at least 1 Black and 1 White beneficiary (96.4% of all beneficiaries). We studied two CMS quality measures: chemotherapy associated ED visits and chemotherapy associated hospitalizations. For each outcome, we estimated multi-level models with separate practice-level random intercepts for Black and White patients to quantify practice-level Black-White disparities in adjusted rates of these measures and assess the associations of these rates with the proportion of Black patients in the practice. Results: Overall, 108,177 Black and 966,381 White beneficiaries with cancer were treated at 1321 practices with reliable estimates (reliability ≥70%) of Black-White differences in rates of chemotherapy-associated ED visits; 101,411 Black and 915,895 White beneficiaries were treated at 1,012 practices with reliable estimates of chemotherapy-associated hospitalizations. These practices treated 80% or more of all Black and White beneficiaries; 10% of these practices treated 75% of Black beneficiaries. The median adjusted Black-White rate difference across practices was +8.9% [interquartile interval (IQI) +5.0%, +12.8%; 5th, 95th percentile -1.8 to +19.2%] for chemotherapy associated ED visits and +4.4% [IQI +1.3%, +7.7%; 5th, 95th percentile -3.5% to +13.5%] for chemotherapy associated hospitalizations. Chemotherapy-associated ED visit rates were 3.2 percentage points higher for Black vs White patients (P <.001) at the practice with the mean % of Black patients, but the difference was smaller in practices with more Black patients (0.4 percentage points less for each 10% increase in Black share, P <.001). Chemotherapy-associated hospitalization rates were 0.6 percentage points lower for Black vs White patients (P =.01) but did not vary by practice racial composition. Conclusions: Using data from more than 1000 practices over 4 years, we calculated reliable estimates of practice-level racial disparities in chemotherapy-associated ED visits and hospitalizations. Practice-level performance for these quality measures was generally lower for Black versus White beneficiaries. Measuring and providing feedback on practice-level Black-White disparities in oncology performance measures may be one effective tool for advancing racial equity in care quality for cancer patients receiving chemotherapy.

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Black and White Patients With Inflammatory Bowel Disease Show Similar Biologic Use Patterns With Medicaid Insurance

Inflammatory Bowel Diseases ◽

10.1093/ibd/izaa090 ◽

2020 ◽

Author(s):

Edward L Barnes ◽

Christina M Bauer ◽

Robert S Sandler ◽

Michael D Kappelman ◽

Millie D Long

Keyword(s):

Inflammatory Bowel Disease ◽

Bowel Disease ◽

Multivariable Analysis ◽

Receive Combination Therapy ◽

Black And White ◽

Black Patients ◽

Significant Difference ◽

Inflammatory Bowel ◽

To Receive ◽

White Patients

Abstract Background Prior studies have identified racial disparities in the treatment and outcomes of inflammatory bowel disease (IBD). These disparities could be secondary to differences in biology, care delivery, or access to appropriate therapy. The primary aim of this study was to compare medication use among Medicaid-insured black and white patients with IBD, given uniform access to gastroenterologists and therapies. Methods We analyzed Medicaid Analytic eXtract data from 4 states (California, Georgia, North Carolina, and Texas) between 2006 and 2011. We compared the use of IBD-specific therapies, including analyses of postoperative therapy among patients with Crohn disease (CD). We performed bivariate analyses and multivariable logistic regression, adjusting for potential confounders. Results We identified 14,735 patients with IBD (4672 black [32%], 8277 with CD [58%]). In multivariable analysis, there was no significant difference in the odds of anti-tumor necrosis factor use by race for CD (adjusted odds ratio [aOR] = 1.13; 95% confidence interval [CI], 0.99-1.28] or ulcerative colitis (aOR = 1.12; 95% CI, 0.96-1.32). Black patients with CD were more likely than white patients to receive combination therapy (aOR = 1.50; 95% CI, 1.15-1.96), and black patients were more likely than white patients to receive immunomodulator monotherapy after surgery for CD (31% vs 18%; P = 0.004). Conclusions In patients with Medicaid insurance, where access to IBD-specific therapy should be similar for all individuals, there was no significant disparity by race in the utilization of IBD-specific therapies. Disparities in IBD treatment discussed in prior literature seem to be driven by socioeconomic or other issues affecting access to care.

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Are there racial differences in the way patients with psychotic disorders are treated at their first hospitalization?

Psychological Medicine ◽

10.1017/s0033291703001363 ◽

2004 ◽

Vol 34 (4) ◽

pp. 705-718 ◽

Cited By ~ 15

Author(s):

NANCY L. SOHLER ◽

EVELYN J. BROMET ◽

JANET LAVELLE ◽

THOMAS J. CRAIG ◽

RAMIN MOJTABAI

Keyword(s):

Racial Differences ◽

Psychotropic Medication ◽

Psychotic Disorders ◽

Medication Use ◽

Patient Treatment ◽

Black And White ◽

Early Stages ◽

Black Patients ◽

Different Types ◽

White Patients

Background. It is now well documented that both black and white patients with severe mental illness are likely to use different types of treatment facilities, have different lengths of hospital stays, and receive different types and dosages of psychotropic medications. It is still uncertain, however, whether these differences exist at the early stages of treatment.Method. We examined treatment patterns for a countywide sample of patients with psychotic disorders recruited at their initial psychiatric hospitalization. Illness characteristics, prior treatment histories, admission conditions, and psychotropic medication use during this hospitalization were compared for both black and white patients.Results. Black patients were less likely to have had out-patient treatment prior to their first hospitalization and were more likely to be hospitalized in public than in community psychiatric units than were white patients. Black patients were also more likely to be hospitalized primarily for a behavioral disturbance and escorted to the hospital by the emergency medical services or police, while white patients were more often hospitalized primarily for subjective suffering. These patterns were particularly significant for those with a non-schizophrenia diagnosis. However, there were few statistically significant differences between black and white patients on psychotropic medication use during the first hospitalization.Conclusions. Differences during the early stages of treatment between black and white patients with psychotic disorders appear to arise most prominently before, rather than during, their first hospitalization.

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Association of Race with In-Hospital and Post-Hospitalization Mortality in Patients with Acute Kidney Injury

Nephron ◽

10.1159/000511405 ◽

2021 ◽

pp. 1-11

Author(s):

Muzamil O. Hassan ◽

Itunu Owoyemi ◽

Emaad M. Abdel-Rahman ◽

Jennie Z. Ma ◽

Rasheed A. Balogun

Keyword(s):

Hospital Mortality ◽

Racial Differences ◽

Survival Curve ◽

Kidney Injury ◽

Term Survival ◽

Long Term Survival ◽

Black And White ◽

Black Patients ◽

White Patients

Introduction: Acute kidney injury (AKI) is known to be associated with increased mortality, and racial differences in hospital mortality exist in patients with AKI. However, it remains to be seen whether racial differences exist in post-hospitalization mortality among AKI patients. Methods: We analyzed data of adult AKI patients admitted to the University of Virginia Medical Center between January 1, 2001, and December 31, 2015, to compare in-hospital and post-hospitalization mortality among hospitalized black and white patients with AKI. Multivariable logistic regression analysis was used to analyze the association between race and in-hospital mortality, and 90-day post-hospitalization mortality among AKI patients that were discharged. Kaplan-Meier survival curve was used to evaluate long-term survival between black and white patients. Results: Black patients had lower in-hospital mortality than white patients after adjusting for age, sex, estimated glomerular filtration rate, hospital length of stay, severity of AKI, comorbidities, and the need for dialysis and mechanical ventilation (odds ratio: 0.82; 95% confidence interval, 0.70–0.96, p = 0.0015). Similarly, at 90-day post-hospitalization, black patients had significantly lower adjusted odds of death than white patients (odds ratio: 0.64; 95% confidence interval, 0.46–0.93; p = 0.008). The median length of follow-up was 11.9 months (0.6–46.7 months). Kaplan-Meier survival curve showed that long-term survival was significantly better in black patients compared to white patients (median duration of survival; 39.7 vs. 24.8 months; p ≤ 0.001). Conclusions: Black patients with AKI had lower in-hospital mortality, 90-day post-hospitalization mortality, and better long-term survival rates compared to white patients with AKI.

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