Racial differences in hospice use and patterns of care after enrollment in hospice among Medicare beneficiaries with heart failure

Abstract

We examined racial differences in patterns of care and resource use among Medicare beneficiaries with heart failure after enrollment in hospice. We conducted a retrospective cohort study of a 5% nationally representative sample of Medicare beneficiaries with heart failure who died between 2000 and 2008. Outcomes of interest included adjusted and unadjusted associations of race with hospice enrollment for any diagnosis, disenrollment, and resource use after enrollment. The study population included 219,275 Medicare beneficiaries with heart failure, of whom 31.4% of white patients and 24.3% of nonwhite patients enrolled in hospice in the last 6 months of life (P < .001). Despite increasing rates of hospice use for both white and nonwhite patients, nonwhite patients were 20% less likely to enroll in hospice (adjusted relative risk, 0.80; 95% CI, 0.79-0.82). After enrollment, nonwhite patients were more likely to have an emergency department visit (42.6% vs 33.9%; P<.001), to be hospitalized (46.8% vs 38.5%; P<.001), and to have an intensive care unit stay (16.9% vs 13.3%; P<.001). These differences persisted after adjustment for patient characteristics. Nonwhite patients were also more likely to disenroll from hospice (11.6% vs 7.2%; P<.001). Among patients who remained in hospice until death, nonwhite patients had higher rates of acute care resource use and higher overall costs. Rates of hospice use have increased over time for both white and nonwhite patients. Nonwhite patients were less likely than white patients to enroll in hospice and had higher resource use after electing hospice care, regardless of disenrollment status.