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

Background: American Indians (AI) experience disparities in cancer outcomes. Little is known about the quality of end-of-life (EOL) care in AI patients with cancer.

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

Results: We identified 163,285 (1,769 AI and 161,516 White) decedents. The majority (60%) of AIs lived in a geographic area characterized by non-federally recognized tribes. AI decedents had greater proportions of rural residence than White decedents (54.5% AI vs 30.4% White) and dual Medicaid/Medicare enrollment (37.4% AI vs 17.7% White). Compared with White decedents, AI decedents had increased hospital admission (aRR, 1.10, 95% confidence interval [CI], 1.06-1.15), ICU admission (aRR, 1.21; 95% CI, 1.11-1.32), and >1 ED visit (aRR, 1.31; 95% CI, 1.20-1.44) in the last 30 days of life. We observed significant within-group variation in EOL care quality among AI patients.

Conclusions: Structural barriers to care and rurality may contribute to lower quality EOL care among AI decendents, when compared with White patients. High-quality, culturally appropriate EOL care will require a better understanding of care decision-making and access.