Sex and Racial/Ethnic Differences in End-of-Life Care in Texan Medicare Colorectal Cancer Decedents

Background: There are known sex and racial/ethnic differences in colorectal cancer care. The purpose of this study is to investigate these differences in end-of-life health care utilization, advance care planning, and associated outcomes among Texan Medicare colorectal cancer decedents. Methods: In this retrospective case control study, we used the Texas Cancer Registry linked with Medicare data for patients (n = 5757) aged ≥66 years who died 6 months to 5 years after receiving a diagnosis of primary colorectal cancer from 2010-2018. We used chi-square tests, t-tests, or ANOVA as appropriate for outcomes in the last 30 days of life to assess sex and racial/ethnic differences. Multivariable logistic regression models were used to assess differences in the odds of inpatient admission and hospice enrollment. Results: Significantly more female decedents were hospice enrolled. Non-Hispanic Black decedents, and to a lesser extent Hispanic decedents, had greater health care utilization, including inpatient stays, and less hospice enrollment compared to non-Hispanic White decedents. Advance care planning was low (≤2.2%) across all groups, with no significant differences. Multivariable logistic regression models showed that female decedents had greater odds of hospice enrollment compared to male decedents, and non-Hispanic Black decedents had greater odds of inpatient stays and decreased odds of hospice enrollment compared to non-Hispanic White decedents. Conclusion: Sex and racial/ethnic disparities in care highlight opportunities for process and quality improvement and suggest a need for practice changes to improve access to quality end-of-life care. More work is needed to incorporate advance care planning and billing into regular workflows.