Hidden figures underlying quality measures: revealing hidden racial inequalities in end-of-life cancer care delivery: a cohort study

Background: Calls for healthcare systems to reduce disparities in cancer care access and outcomes draw on comparisons of existing measures across race and ethnicity subgroups. This approach may hide inequities driven by systematic bias in the timing of care delivery. The goals of this study were to: (1) identify differences in the timing of care delivery between racial groups, and (2) determine whether these differences could be identified from quality measures. Methods: Retrospective decedent follow-back study of hospitals treating Medicare fee-for-service beneficiaries with advanced cancer aged 65–99 who died April–December 2016. Among hospitals serving at least 11 decedents of color (including Black or African-American, Asian/Pacific Islander, Hispanic, American Indian/Alaska Native, and Other) and 11 White decedents, we calculated hospital-level differences between White decedents and decedents of color for 1) any use of palliative care and hospice (Measures) and 2) daily counts of palliative care and hospice use for each day in the 6 months before death (Signatures). Findings: The cohort included 30,319 decedents across 217 hospitals, of whom 7,852 (25.9%) were people of color (POC). The median of the hospital-specific aggregate measure difference was −5.35% (IQR = 12.83) for palliative care, indicating more POC received any palliative care, and 3.66% (IQR = 12.45) for hospice care, indicating more White people (WP) received any hospice care. We identified 5 high-level cluster-group descriptions of inequality from signatures. Inequality information from signatures matched those from measures in only 46.5% and 39.2% of hospitals for palliative and hospice care, respectively. Interpretation: Signatures incorporating timing of care delivery using longitudinal data revealed patterns of racial-ethnic inequalities in end-of-life cancer care otherwise missed by traditional aggregate quality measures. Funding: This work was supported by the American Cancer Society Award (RSG-22-128-01-HOPS).