Likelihood of Death at Home Is Improving in Colorectal Cancer, but Sociodemographic Disparities Persist
Key findings
- This retrospective study investigated trends in the location of death and determinants of the location in 850,750 patients who died from colorectal cancer in the U.S. between 2003 and 2019
- Home death was the most common location of death (42% of patients)
- Deaths at home or hospice increased over time during the study period, driven by increases among racial and ethnic minorities, while deaths in institutionalized settings declined, driven by white and non-Hispanic populations
- These data suggest there are multiple needs to reduce inequity in access to preferred locations of death
- Still, the lowest incidence of dying at home was linked to having multiple causes of death (more comorbidities), so clinical factors might best explain the location of death due to colorectal cancer
Death at home is a strong preference of many patients with advanced cancers and their families. However, a discrepancy between the preferred and actual location of death is well known and may be driven by sociodemographic factors.
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In a nationwide retrospective study, Massachusetts General Hospital researchers documented a gradual shift in the location of death of U.S. patients who die of colorectal cancer (CRC), from institutionalized settings to home. However, the data confirmed that some sociodemographic groups are proportionately more likely to die in hospitals compared with home or hospice.
David L. Berger, MD, a colorectal and gastrointestinal surgeon in the Division of Gastrointestinal & Oncologic Surgery, Swati Sonal, MBBS, a prior research fellow in the Division, and colleagues detail the findings in Annals of Surgical Oncology.
Methods
The data source for the study was the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database, which contains data from all death certificates submitted by the states to the U.S. government.
Individuals included in the study died between 2003 and 2019 and had CRC listed as the underlying cause of death (and not a secondary cause of death).
Characteristics of the Cohort
850,750 individuals died due to CRC within the study period and had complete data available. 59% were elderly (≥70 years old) and 52% were males. Race was categorized as white (83.65%), Black (12.95%), Asian (2.83%), and American Indian/Alaska Native (AIAN, 0.57%). Most decedents were non-Hispanic (94%) and 53% had multiple causes of death. 35% had at least some college education.
Overall, the location of death was categorized as home (41.92%), hospital (25.29%), nursing home (16.4%), hospice (9.13%), or outpatient medical facility/emergency department (7.26%).
Trends Over Time
The proportion of deaths at home and hospice increased during the study period while deaths in the other locations declined. When analyzed by race or ethnicity:
- The increase in home and hospice deaths was driven by the racial minority category while the decline in hospital deaths was driven by the white category
- The Hispanic category drove the rise in the proportion of home deaths over time, but hospice deaths remained constant over time for both Hispanic and non-Hispanic categories
- The Hispanic category primarily drove the decline in deaths in institutionalized settings (excluding hospice)
These findings suggest multiple opportunities for improvement to reduce inequity in access to the preferred location of death.
Multivariate Analysis
On multivariate analysis, factors significantly associated with the incidence of home death compared with hospital death were:
- Age—Relative risk ratio (RRR) 1.09 for every 10-year increase
- Sex—RRR 0.89 for men vs. women
- Race—RRR 0.64, 0.75, and 0.90 for the Black, Asian, and AIAN groups, respectively, vs. the white group
- Ethnicity—RRR 1.03 for Hispanic ethnicity vs. non-Hispanic
- Marital status—RRR 1.31 for married people vs. unmarried
- Education—RRR 1.02 for people with at least some college vs. those with less education
Older age, female sex, white race, and higher education were also significantly associated with a greater incidence of hospice death compared with hospital death.
Influence of Comorbidities
The relationship of comorbidities with the location of death was measured indirectly by comparing patients with a single cause of death to those with multiple causes.
Multiple causes of death were associated with a significantly lower likelihood of dying at home or in hospice (RRR, 0.32), lower than for any other variable analyzed. Although clear racial, ethnic, and social disparities exist, factors surrounding the location of death due to CRC may be predominantly clinical.
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