Abstract
Although hospice use is increasing and patients in the US are increasingly dying at home, racial disparities in treatment intensity at the end of life, including hospice use, remain. To examine differences between Black and White patients in end-of-life care in a population sample with well-characterized causes of death. This study used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, an ongoing population-based cohort study with enrollment between January 25, 2003, and October 3, 2007, with linkage to Medicare claims data. Multivariable logistic regression models were used to examine racial and regional differences in end-of-life outcomes and in stroke mortality among 1212 participants with fee-for-service Medicare who died between January 1, 2013, and December 31, 2015, owing to natural causes and excluding sudden death, with oversampling of Black individuals and residents of Southeastern states in the United States. Initial analyses were conducted in March 2019, and final primary analyses were conducted in February 2020. The primary outcomes of interest were hospice use of 3 or more days in the last 6 months of life derived from Medicare claims files. Other outcomes included multiple hospitalizations, emergency department visits, and use of intensive procedures in the last 6 months of life. Cause of death was adjudicated by an expert panel of clinicians using death certificates, proxy interviews, autopsy reports, and medical records. The sample consisted of 1212 participants (630 men [52.0%]; 378 Black individuals [31.2%]; mean [SD] age at death, 81.0 [8.6] years) of 2542 total deaths. Black decedents were less likely than White decedents to use hospice for 3 or more days (132 of 378 [34.9%] vs 385 of 834 [46.2%]; P < .001). After stratification by cause of death, substantial racial differences in treatment intensity and service use were found among persons who died of cardiovascular disease but not among patients who died of cancer. In analyses adjusted for cause of death (dementia, cancer, cardiovascular disease, and other) and clinical and demographic variables, Black decedents were significantly less likely to use 3 or more days of hospice (odds ratio [OR], 0.72; 95% CI, 0.54-0.96) and were more likely to have multiple emergency department visits (OR, 1.35; 95% CI, 1.01-1.80) and hospitalizations (OR, 1.39; 95% CI, 1.02-1.89) and undergo intensive treatment (OR, 1.94; 95% CI, 1.40-2.70) in the last 6 months of life compared with White decedents. Despite the increase in the use of hospice care in recent decades, racial disparities in the use of hospice remain, especially for noncancer deaths. More research is required to better understand racial disparities in access to and quality of end-of-life care.
Highlights
Consistent with patient preferences to avoid intensive hospital-based care at the end of life,[1,2] in 2017, most US patients died at home.[3]
After stratification by cause of death, substantial racial differences in treatment intensity and service use were found among persons who died of cardiovascular disease but not among patients who died of cancer
In analyses adjusted for cause of death and clinical and demographic variables, Black decedents were significantly less likely to use 3 or more days of hospice and were more likely to have multiple emergency department visits (OR, 1.35; 95% CI, 1.01-1.80) and hospitalizations (OR, 1.39; 95% CI, 1.02-1.89) and undergo intensive treatment (OR, 1.94; 95% CI, 1.40-2.70) in the last 6 months of life compared with White decedents
Summary
Consistent with patient preferences to avoid intensive hospital-based care at the end of life,[1,2] in 2017, most US patients died at home.[3] Use of hospice care is on the rise in the United States—with most deaths of Medicare beneficiaries occurring while receiving hospice care, a significant increase in the last decade.[4] The fastest-growing segment of the population receiving hospice care includes individuals with noncancer diagnoses.[5] Despite the potential benefits of hospice enrollment for individuals and families, including enhanced quality of life for patients near the end of life[6,7,8] and decreased Medicare costs,[9] half of patients with terminal illnesses still do not use hospice care.[10] most individuals who use hospice care are admitted very close to the end of life. Short hospice stays (Յ3 days) have increased to 28.4% of all hospice stays,[10] and 14.3% of patients with cancer who enroll in hospice do so in the last 3 days of life.[11] In addition, high-intensity treatments at the end of life remain common despite patient preferences to avoid such care. Among Medicare beneficiaries, intensive care unit use in the last month of life increased from 24% in 2000 to 29% in 2015.4
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