Disparities in Terminal Hospitalization Among Adults With Metastatic Cancer

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In a retrospective population-based study reported in JAMA Network Open, Deeb et al found that patients with metastatic cancer from racial and ethnic minority groups and those without private insurance were more likely to be admitted from the emergency department, receive invasive mechanical ventilation, have longer hospital stays, and incur greater charges during terminal hospitalization.

As stated by the investigators, “Many patients with metastatic cancer receive high-cost, low-value care near the end of life. Identifying patients with a high likelihood of receiving low-value care is an important step to improve appropriate end-of-life care.”

The study used data from the Healthcare Cost and Utilization Project on 21,335 patients aged ≥ 18 years at inpatient admission with a principal diagnosis of metastatic cancer who died during hospitalization between January 20210 and December 2017.

Key Findings

Among the 21,335 patients, median age was 65 years (interquartile range = 56–75 years); 54.0% were female; 0.5% were Native American, 3.3% were Asian/Pacific Islander, 14.1% were Black, 7.5% were Hispanic, and 65.9% were White; 58.2% had Medicare or Medicaid and 33.2% had private insurance.

Overall, 63.2% of patients were admitted from the emergency department; 4.6% received systemic therapy and 19.2% received invasive mechanical ventilation during hospitalization.

Compared with White patients: 

  • Higher likelihood of admission from the emergency department was found for Asian/Pacific Islander patients (odds ratio [OR] = 1.43, P < .001), Black patients (OR = 1.39, P < .001), and Hispanic patients (OR = 1.45, P < .001)
  • Higher likelihood of receiving invasive mechanical ventilation was found for Black patients (OR = 1.59, P < .001)
  • Lower likelihood of receiving systemic therapy was found for Black patients (OR = 0.78, P = .02)
  • Higher likelihood of a hospital stay longer than the median length for the entire cohort was found for Black patients (OR = 1.21, P <.0001) and Asian/Pacific Islander patients (OR = 1.21, P = .021)
  • Likelihood of incurring higher total charges was found for Asian/Pacific Islander patients (OR = 1.35, P = .001), Black patients (OR = 1.23, P < .001), and Hispanic patients (OR = 1.50, P < .001).

Compared with patients with Medicare and Medicaid, privately insured patients had a lower likelihood of being admitted from the emergency department (OR = 0.47, P < .001), receiving invasive mechanical ventilation (OR = 0.75, P < .001), having a longer-than-median hospital stay (OR = 0.72, P < .0001), and incurring higher total charges (OR = 0.64, P < .001).

The investigators concluded, “In this study, patients with metastatic cancer from racial and ethnic minority groups and those with Medicare or Medicaid coverage were more likely to receive low-value, aggressive interventions at the end of life. Further studies are needed to evaluate the underlying factors associated with disparities at the end of life to implement prospective interventions.”

Jillian Tsai, MD, PhD, of the Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, is the corresponding author for the JAMA Network Open article.

Disclosure: This study was funded by grants from the National Institutes of Health and National Cancer Institute. For full disclosures of the study authors, visit

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.