Association of socioeconomic status with aggressive end-of-life care in patients with cancer before and during the COVID-19 pandemic.
Authors: Iqbal Javaid , Moineddin Rahim , Fowler Robert A , Booth Christopher M. , Downar James , Lau Jenny , Le Lisa , Rodin Gary , Seow Hsien , Tanuseputro Peter , Earle Craig , Quinn Kieran L , Krzyzanowska Monika K. , Hannon Breffni , Zimmermann Camilla 
Published: May 2024

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Background: Aggressive care near the end-of-life (EOL) reflects poor quality of cancer care.We examined the association between trends in aggressive EOL cancer care and socioeconomic status (SES) before and during the COVID-19 pandemic. Methods: We conducted a population-based cohort study of adults diagnosed with cancer who died from 03/16/2015 to 03/15/2020 (pre-COVID-19 period) and from 03/16/2020 to 03/15/2021 (COVID-19 period). Aggressive EOL care was defined as a composite outcome of percentage (%) of patients with systemic anticancer therapy (SACT) use, >1 ED visit, >1 hospitalization, or ≥1 ICU admission in the last 30 days of life. We conducted an interrupted time series analysis using segmented linear regression, estimating monthly trends before, at the start of, and during the first year of the pandemic. Analyses were stratified by SES, based on area-level material deprivation quintiles (Q1, least; Q3, intermediate; Q5, most deprived). Results: Of 173,915 decedents with cancer (mean [SD] age 72.1 [12.5] years; females 45.9%), 59,613 (34.3% [95% CI, 34.1-34.5]) had aggressive EOL care; 10.3% (10.2-10.5) received SACT, 14.0% (13.8-14.2) had >1 ED visit, 10.3% (10.2-10.5) >1 hospitalization, and 13.4% (13.2-13.5) ≥1 ICU admission within 30 days of death. During the course of the pre-COVID-19 period, patients in Q1 (33.5% [33.0-34.1]) were less likely to receive aggressive care at the EOL than those in Q3 (34.1% [33.5-34.6]) or Q5 (34.8%, 95% CI, 34.3-35.3). Specifically, patients in Q1 were less likely to have ED visits (Q1, 12.9% vs Q3, 14.2% vs Q5, 14.9%), and hospitalizations (9.7% vs 10.3% vs 10.6%) than Q3 and Q5, and less likely to have ICU admissions than Q5 (13.1 vs 13.0% vs 14.4%); however, they were more likely to receive SACT at EOL (11.1% vs 9.9% vs 9.1%). During the pre-COVID-19 period, aggressive care increased by 0.032% (95% CI, 0.026-0.038, P < 0.0001) monthly; this increase was significant in Q1 (P = 0.002)but not in Q3 (P = 0.31) or Q5 (P = 0.21). Within Q1, there was a pre-COVID-19 increase in EOL SACT use (P < 0.0001)and ED visits (P = 0.04) but not inhospitalizations and ICU admissions. In March 2020, aggressiveness of care decreased by 2.37% (95% CI, -2.98 to -1.76, P = 0.0002), which was significant in Q5 (P = 0.04), but not Q1 (P = 0.07)or Q3 (P = 0.81). Within Q5, there was a decrease in EOL ED visits (P = 0.0008) but not in SACT use, hospitalizations, or ICU admissions. Conclusions: More than one third of adults with advanced cancer received aggressive EOL care, which increased in the 5 years prior to COVID-19 pandemic and was attenuated at its onset. Indicators of aggressive care differed by SES, with greatest SACT use in those with highest SES and greatest hospital services use in those with lowest SES. Measures to reduce aggressiveness of care should take into account disparities related to SES.