Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA.
Pediatric Hematology/Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
Pediatr Blood Cancer. 2022 Aug;69(8):e29521. doi: 10.1002/pbc.29521. Epub 2021 Dec 28.
Disparities in end-of-life (EOL) care for children with cancer remain understudied. We addressed this gap by examining patterns of EOL care, with a focus on location of death and hospice utilization.
We used MarketScan - a nationally representative dataset with Medicaid and commercial claims to conduct a retrospective observational study of children with cancer who died between 2011 and 2017 at age ≤21 years. We examined rates of (a) home death, (b) hospice utilization, (c) and medically intense interventions in the last 30 days (e.g., intubation).
Of the 1492 children in the cohort, 44% had Medicaid and 56% commercial insurance; 71% carried a solid tumor diagnosis, and 37% were between the ages of 15 and 21 years at the time of death. Forty percent died at home; children with Medicaid were less likely to die at home (relative risk [RR] = 0.82, 95% confidence interval [CI]: 0.73-0.92; reference: commercial). Forty-five percent enrolled in hospice, for a median of 2 days. Hospice enrollment rates did not vary with insurance. However, children with Medicaid spent less time enrolled (incidence rate ratio [IRR] = 0.22, 95% CI: 0.17-0.27). Among children with Medicaid, Black children were less likely to die at home (RR = 0.69, 95% CI: 0.52-0.92) and enroll on hospice (RR = 0.71, 95% CI: 0.55-0.91) than non-Hispanic White children. Medically intense interventions did not vary with insurance or race.
Only 40% of children with cancer die at home, and the duration of hospice enrollment is short. EOL care varies significantly with insurance. It is imperative that we determine if these patterns and disparities represent EOL preferences, provider biases, or differences in quality or availability of hospice.
儿童癌症患者在临终关怀方面的差异仍然研究不足。我们通过研究临终关怀模式来解决这一差距，重点关注死亡地点和临终关怀的利用情况。
我们使用 MarketScan-一个具有医疗补助和商业索赔的全国代表性数据集，对 2011 年至 2017 年间年龄≤21 岁的癌症死亡儿童进行回顾性观察研究。我们检查了以下几种情况的发生率：（a）在家中死亡，（b）使用临终关怀，（c）在最后 30 天内进行医疗干预（如插管）。
在队列中的 1492 名儿童中，44%有医疗补助，56%有商业保险；71%患有实体瘤，37%在死亡时年龄在 15 至 21 岁之间。40%的儿童在家中死亡；有医疗补助的儿童在家中死亡的可能性较低（相对风险 [RR] = 0.82，95%置信区间 [CI]：0.73-0.92；参考：商业）。45%的儿童入组临终关怀，中位时间为 2 天。临终关怀的入组率与保险类型无关。然而，有医疗补助的儿童入组时间较短（发病率比 [IRR] = 0.22，95%CI：0.17-0.27）。在有医疗补助的儿童中，黑人儿童在家中死亡的可能性较低（RR = 0.69，95%CI：0.52-0.92），入组临终关怀的可能性也较低（RR = 0.71，95%CI：0.55-0.91），而非西班牙裔白人儿童。医疗干预的强度与保险或种族无关。
只有 40%的癌症儿童在家中死亡，临终关怀的入组时间很短。临终关怀的利用情况因保险类型而有很大差异。我们必须确定这些模式和差异是否代表临终偏好、提供者偏见，还是临终关怀的质量或可用性的差异。
