Disparities In Hospice Use Research Articles

Hospice Knowledge, Attitudes, and Preference among Older Chinese Immigrants in the United States

Racial disparities in hospice use are a longstanding concern in the U.S. Asian Americans are among the least likely to receive hospice care and to be included in studies on this topic. This study examined the knowledge, attitudes, and preferences related to hospice care among older Chinese immigrants and associated factors. A sample of 262 Chinese immigrants age 60+ was recruited from six older adult centers in NYC. In-person interviews were conducted in Mandarin and Cantonese. Non-English-speaking older Chinese immigrants had very limited knowledge about hospice care. Only 26% of respondents had heard of hospice, and a few could correctly define any components. After receiving a comprehensive definition of hospice care, study participants expressed a positive attitude and a strong willingness to use hospice if near the end of life. Notably, some respondents still held misconceptions about hospice and were less positive in their attitude and preference for hospice care. These findings underscore the necessity for clear and accessible information about hospice among this population throughout the trajectory from good health to end of life. Further research is needed to identify the range of factors that influence the attitudes and preferences of older Chinese immigrants toward hospice care.

The Medicare Care Choices Model was associated with reductions in disparities in the use of hospice care for Medicare beneficiaries with terminal illness.

To assess the effects of the Medicare Care Choices Model (MCCM) on disparities in hospice use and quality of end-of-life care for Medicare beneficiaries from underserved groups-those from racial and ethnic minority groups, dually eligible for Medicare and Medicaid, or living in rural areas. Medicare enrollment and claims data from 2013 to 2021 for terminally ill Medicare fee-for-service beneficiaries nationwide. Through MCCM, terminally ill enrolled Medicare beneficiaries received supportive and palliative care services from hospice providers concurrently with curative treatments. Using a matched comparison group, we estimated subgroup-specific effects on hospice use, days at home, and aggressive treatment and multiple emergency department visits in the last 30 days of life. The sample included decedent Medicare beneficiaries enrolled in MCCM and a matched comparison group from the same geographic areas who met model eligibility criteria at time of enrollment: having a diagnosis of cancer, congestive heart failure, chronic obstructive pulmonary disease, or HIV/AIDS; living in the community; not enrolled in the Medicare hospice benefit in the previous 30 days; and having at least one hospital stay and three office visits in the previous 12 months. Eligible beneficiaries from underserved groups were underrepresented in MCCM. MCCM increased enrollees' hospice use and the number of days at home and reduced aggressive treatment among all subgroups analyzed. MCCM also reduced disparities in hospice use by race and ethnicity and dual eligibility by 4.1 (90% credible interval [CI]: 1.3-6.1) and 2.4 (90% CI: 0.6-4.4) percentage points, respectively. It also reduced disparities in having multiple emergency department visits for rural enrollees by 1.3 (90% CI: 0.1-2.7) percentage points. MCCM increased hospice use and quality of end-of-life care for model enrollees from underserved groups and reduced disparities in hospice use and having multiple emergency department visits.

Factors Associated With Mortality and Hospice Use Among Medicare Beneficiaries With Heart Failure Who Received Home Health Services

Background: Although many Medicare beneficiaries with heart failure (HF) are discharged with home health services, little is known about mortality and hospice use in this group. Objectives: To identify risk factors of 6-month mortality and hospice use among hospitalized HF patients who receive home health, which could inform efforts to improve palliative and hospice use for these patients. Methods: A retrospective cohort analysis was conducted in a 100% national sample of Medicare fee-for-service beneficiaries with HF discharged with home health from 2017-2018. Multivariable Cox regression models examined factors associated with 6-month mortality and multivariable logistic regression models examined factors associated with hospice use at the time of death. Results: 285,359 Medicare beneficiaries were hospitalized with HF and discharged with home health; 15.5% (44,174) died within 6 months. Variables most strongly associated with mortality included: age >85 years [Hazard Ratio (HR) 1.66, 95% CI 1.61-1.71], urgent/emergency hospital admission (HR 1.68, 1.61-1.76), and “serious” condition compared to “stable” condition (HR 1.64, CI 1.52-1.78). Among 44,174 decedents, 48.2% (21,284) received hospice at the time of death. Those with lower odds of hospice use at death included patients who were: <65 years [Odds Ratio (OR) 0.65, CI 0.59-0.72]; Black (OR 0.64, CI 0.59-0.68) or Hispanic race/ethnicity (OR 0.79, CI 0.72-0.88); and Medicaid-eligible (OR 0.80, CI 0.76-0.85). Conclusions: Although many patients hospitalized for HF are at risk for 6-month mortality and may benefit from palliative and/or hospice services, our findings indicate under-utilization of hospice and important disparities in hospice use by race/ethnicity and socioeconomic status.

Local Area Hospice Capacity and Rural Disparities in Hospice Use among Older Adults with Metastatic Breast Cancer.

Background: Little is known about how local area hospice capacity and staffing levels impact hospice use in urban versus rural areas. Objectives: To examine the association between local hospice capacity and staffing levels and hospice use in the context of rural disparities in hospice use, among a sample of patients with metastatic breast cancer. Design: A retrospective cohort study using Surveillance Epidemiology End-Results (SEER)-Medicare linked data 2000-2010, Medicare Provider of Service files, and Census 2000 U.S. Zip Code Tabulation Areas files. Setting: Use of Medicare-certified hospice programs among older adults with metastatic breast cancer residing in one of the SEER program cancer registries designated by National Cancer Institute in the United States. Measurements: Measurements of geographic access to hospices include urban/rural characteristics of patient residence and driving time from the nearest Medicare-certified hospice headquarter. Measurements of local-area hospice capacity and staffing levels include per capita number of Medicare-certified hospice programs and full-time employees among older adults within a predefined radius. Results: Among the study population (N = 5418), remote and suburban areas were negatively associated with hospice use. Lower hospice use in remote and suburban areas was associated with fewer per capita number of Medicare-certified hospice program employees in local areas ≥70-minute driving radius (p = 0.0042), while per capita number of Medicare-certified hospice programs in local areas showed no impact. Conclusion: For older patients with metastatic breast cancer, availability of hospice staff, rather than driving distance or the number of hospice agencies, may limit hospice use in remote and suburban areas.

Local Area Hospice Capacity and Rural Disparities in Hospice Use Among Older Adults with Metastatic Breast Cancer (GP741)

Local Area Hospice Capacity and Rural Disparities in Hospice Use Among Older Adults with Metastatic Breast Cancer (GP741)

Patient Navigator and Community Health Worker Attitudes Toward End-of-Life Care.

Background: There are racial/ethnic disparities in hospice use and end-of-life (EOL) care outcomes in the United States. Although the use of community health workers (CHWs) and patient navigators (PNs) has been suggested as a means of reducing them, CHW/PNs' attitudes toward a palliative care philosophy remain unknown. The purpose of this study was to examine how personal attributes affect a CHW/PN's attitude toward EOL care. Methods: CHWs/PNs were recruited from two state-wide organizations and invited to complete an online survey. We collected information on demographics, attitudes toward the palliative care philosophy, and comfort with caring for patients at the EOL. Results: Of the 70 CHWs/PNs who responded to the survey, 82.5% identified as female, 56.4% identified as black, and 56.2% had a four-year college degree or higher. The mean score on a validated scale to assess attitudes toward EOL care was 33.5 (SD = 4.9; possible range, 8-40). Eighty percent strongly agreed or agreed with being open to discussing death with a dying patient. Higher self-efficacy scores were associated with more favorable attitudes toward hospice (r = 0.306, p = 0.016). Conclusions: CHWs/PNs have an overall favorable attitude toward the palliative care philosophy and may be inclined to providing EOL care.

Evaluating the Contribution of Patient-Provider Communication and Cancer Diagnosis to Racial Disparities in End-of-Life Care Among Medicare Beneficiaries.

The quality of end-of-life (EOL) care in the USA remains suboptimal, with significant variations in care by race and across disease subgroups. Patient-provider communication may contribute to racial and disease-specific variations in EOL care outcomes. We examined racial disparities in EOL care, by disease group (cancer vs. non-cancer), and assessed whether racial differences in patient-provider communication accounted for observed disparities. Retrospective cohort study using the 2001-2015 Surveillance, Epidemiology, and End Results - Consumer Assessment of Healthcare Providers and Systems data linked with Medicare claims (SEER-CAHPS). We employed stratified propensity score matching and modified Poisson regression analyses, adjusting for clinical and demographic characteristics PARTICIPANTS: Black and White Medicare beneficiaries 65 years or older with cancer (N=2000) or without cancer (N=11,524). End-of-life care measures included hospice use, inpatient hospitalizations, intensive care unit (ICU) stays, and emergency department (ED) visits, during the 90 days prior to death. When considering all conditions together (cancer + non-cancer), Black beneficiaries were 26% less likely than their Whites counterparts to enroll in hospice (adjusted risk ratio [ARR]: 0.74, 95%CI: 0.66-0.83). Among beneficiaries without cancer, Black beneficiaries had a 32% lower likelihood of enrolling in hospice (ARR: 0.68, 95%CI: 0.59-0.79). There was no racial difference in hospice enrollment among cancer patients. Black beneficiaries were also at increased risk for ED use (ARR: 1.12, 95%CI: 1.01-1.26). Patient-provider communication did not explain racial disparities in hospice or ED use. There were no racial differences in hospitalizations or ICU admissions. We observed racial disparities in hospice use and ED visits in the 90 days prior to death among Medicare beneficiaries; however, hospice disparities were largely driven by patients without cancer. Condition-specific differences in palliative care integration at the end-of-life may partly account for variations in EOL care disparities across disease groups.

Evaluation of Racial Disparities in Hospice Use and End-of-Life Treatment Intensity in the REGARDS Cohort

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.

Family Caregiving at the End of Life and Hospice Use: A National Study of Medicare Beneficiaries.

Hospice care confers well-documented benefits to patients and their families, but it is underutilized. One potential reason is inadequate family support to make end-of-life decisions and care for older adults on hospice at home. We assessed the association between amount of family support and hospice use among a population of decedents and among specific illness types. Prospective cohort study using the National Health and Aging Trends Study waves 2011 to 2017, linked to Medicare claims data. Contiguous United States. A total of 1,868 NHATS decedents. Outcome variable was 1 day or longer of hospice. Family caregiving intensity was measured by self-reported hours of care per week and number of caregivers. Covariates included probable dementia status and other demographic, clinical, and functional characteristics. At the end of life, hours of family caregiving and numbers of helpers vary widely with individuals with dementia receiving the most hours of unpaid care (mean = 64.5 hours per week) and having 2.4 unpaid caregivers on average. In an adjusted analysis, older adults with cancer receiving 40 hours and more of unpaid care/week as compared with fewer than 6 hours per week were twice as likely to receive hospice care at the end of life (odds ratio = 2.0; 95% confidence interval = 1.0-4.1). This association was not seen among those with dementia or among decedents in general. No significant association was found between number of caregivers and hospice use at the end of life. Older adults at the end of life receive a high number of hours of help at the end of life, many from more than one caregiver, which may shape hospice access. Better understanding of disparities in hospice use can facilitate timely access to care for older adults with a serious illness. J Am Geriatr Soc 68:2288-2296, 2020.

RACIAL DISPARITIES IN HOSPICE USE AT THE END OF LIFE: FINDINGS FROM THE REGARDS STUDY

Hospice supports patients and families through interdisciplinary care focused on symptom management and maximization of quality of life. Although hospice care confers well-documented benefits, it remains underutilized: many patients do not use it at all or enter care too late to receive any benefit. While racial disparities in hospice use have been documented, hospice utilization among non-white decedents remains understudied, particularly among those with non-cancer diagnoses. Therefore, we used the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, a population-based investigation of stroke incidence with oversampling of Blacks and cause of death adjudication by expert panel review, linked to Medicare claims data to examine racial disparities in end-of-life care. We identified 1221 participants who died between 2013-2015 due to natural causes excluding sudden death. More than half (52.8%) used hospice during the last 6 months of life (median =15 days), with use among cancer decedents over 70%. Overall, Blacks were significantly less likely to use hospice (OR=0.570) compared to Whites in adjusted analyses. Among hospice users, Blacks did not significantly differ from Whites in length of stay. In analyses stratified by cause of death (dementia, cancer, CVD and other), Blacks were significantly less likely than Whites to use hospice for all causes of death other than dementia. Despite tremendous growth of hospice in recent decades, our findings suggest that this effective service remains highly underutilized among Blacks dying from cancer, CVD and other serious illnesses, suggesting a need for targeted intervention to eliminate disparities in quality end-of-life care.

Investigation of Racial Disparities in Early Supportive Medication Use and End-of-Life Care Among Medicare Beneficiaries With Stage IV Breast Cancer.

Early supportive care may improve quality of life and end-of-life care among patients with cancer. We assessed racial disparities in early use of medications for common cancer symptoms (depression, anxiety, insomnia) and whether these potential disparities modify end-of-life care. We used 2007 to 2012 SEER-Medicare data to evaluate use of supportive medications (opioid pain medications and nonopioid psychotropics, including antidepressants/anxiolytics and sleep aids) in the 90 days postdiagnosis among black and white women with stage IV breast cancer who died between 2007 and 2012. We used modified Poisson regression to assess the relationship between race and supportive treatment use and end-of-life care (hospice, intensive care unit, more than one emergency department visit or hospitalization 30 days before death, in-hospital death). The study included 752 white and 131 black women. We observed disparities in nonopioid psychotropic use between black and white women (adjusted risk ratio [aRR], 0.51; 95% CI, 0.35 to 0.74) but not in opioid pain medication use. There were also disparities in hospice use (aRR, 0.86; 95% CI, 0.74 to 0.99), intensive care unit admission or more than one emergency department visit or hospitalization 30 days before death (aRR, 1.28; 95% CI, 1.01 to 1.63), and risk of dying in the hospital (aRR, 1.59; 95% CI, 1.22 to 2.09). Supportive medication use did not attenuate end-of-life care disparities. We observed racial disparities in early supportive medication use among patients with stage IV breast cancer. Although they did not clearly attenuate end-of-life care disparities, medication use disparities may be of concern if they point to disparities in adequacy of symptom management given the potential implications for quality of life.

Spousal Characteristics and Older Adults' Hospice Use: Understanding Disparities in End-of-Life Care.

Hospice use has been shown to benefit quality of life for patients with terminal illness and their families, with further evidence of cost savings for Medicare and other payers. While disparities in hospice use by patient diagnosis, race, and region are well documented and attention to the role of family members in end-of-life decision-making is increasing, the influence of spousal characteristics on the decision to use hospice is unknown. To determine the association between spousal characteristics and hospice use. We used data from the Health and Retirement Study (HRS), a prospective cohort study, linked to the Dartmouth Atlas of Health Care and Medicare claims. National study of 1567 decedents who were married or partnered at the time of death (2000-2011). Hospice use at least 1 day in the last year of life as measured via Medicare claims data. Spousal factors (e.g., education and health status) measured via survey. In multivariate models controlling for patient factors and regional variation, spouses with lower educational attainment than their deceased spouse had decreased likelihood of hospice use (odds ratio [OR] = 0.58; 95% confidence interval [CI] = 0.40-0.82). Health of the spouse was not significantly associated with likelihood of decedent hospice use in adjusted models. Although the health of the surviving spouse was not associated with hospice use, their educational level was a predictor of hospice use. Spousal and family characteristics, including educational attainment, should be examined further in relation to disparities in hospice use. Efforts to increase access to high-quality end-of-life care for individuals with serious illness must also address the needs and concerns of caregivers and family.

Disparities in hospice use among patients with cancer in the Deep South.

6561 Background: Higher rates of hospice use are an indicator for high-quality end-of-life care for cancer patients, however disparities have been reported. Known racial disparities in hospice util...

Quality of end-of-life care among rural Medicare beneficiaries with colorectal cancer.

Although previous research has documented rural disparities in hospice use, limited data exist on the roles of geographic access in different types of end-of-life indicators among cancer survivors. Medicare claims data were used to identify beneficiaries with colorectal cancer who died in 2008 (N = 34,975). We evaluated rural-urban differences in ER visits 90 days before death, inpatient hospital admissions ≤90 days before death, intensive care unit (ICU) use ≤90 days before death, hospice care use at any time, and hospice enrollment <3 days before death. About 60% of beneficiaries in rural areas lived in counties with the 2 lowest socioecomonic levels compared to only 5.3% of beneficiaries in metropolitan areas. After adjusting for demographic factors and comorbidities, beneficiaries in rural counties had a lower number of ICU days (RR = 0.65) and were less likely to ever use hospice (OR = 0.78) compared to those in metropolitan counties. Beneficiaries from racial/ethnic minority groups, those with lower socioeconomic status, and those with a higher comorbidity index were less likely to ever use hospice but they tended to use ER, inpatient care, and ICU. Evidence for disparities due to geographic access and socioeconomic factors warrant increased efforts to remove systemic and structural barriers. Future research should focus on exploring and evaluating potential policy and practice interventions to improve the quality of life among elderly cancer survivors living in rural communities and those from socioeconomically disadvantaged backgrounds.

An Examination of End-of-Life Care in a Safety Net Hospital System: A Decade in Review

To examine patterns of use of end-of-life care in patients receiving treatment at a large, urban safety-net hospital from 2000 to 2010. Data from the Parkland Hospital palliative care database, which tracked all consults for this period, were analyzed. Logistic regression was used to identify predictors of hospice use, and Cox proportional hazards modeling to examine survival. There were 5,083 palliative care consults over the study period. More patients were Black (41%) or White (31%), and younger than 65 years old (75%). Cancer patients or those who received palliative care services longer were more likely to receive hospice; those who had no form of health care assistance were less likely. There were no racial/ethnic differences in hospice use. In this cohort, there were no racial/ethnic disparities in hospice use. Those who had no form of health care assistance were less likely to receive hospice.

Opening It Up For More Questions: Racial Disparities in Hospice Use

more evenly serve our patients. The study by Johnson et al. focuses on differences in hospice use between black and white patients. Prior research has shown wide geographic variation in hospice use among racial groups. This study evaluated whether racial variation held true at the county level in the Carolinas. What they found was a statistically significant racial variation in just under a third of the counties studieddthis was not particularly surprising. What was surprising and interesting was the finding that, in counties with black-white disparities, there was a significant association with a greater number of hospital beds, physicians per older person, hospices, and a higher proportion of nongeneralist physicians. Fewer blacks used hospice in counties where specialists and hospitals were highly available. As the authors note, key questions remain unanswered. How do patient preferences and clinician behaviors influence observed disparities? How does the matching of treatment to goals influence patient satisfaction? The authors attribute this difference to previously documented variance in preference for using hospital resources when available, but there

Race and Residence: County-Level Variation in Black-White Disparities in Hospice Use (312-B)

Race and Residence: County-Level Variation in Black-White Disparities in Hospice Use (312-B)

Geographic Access to Hospice in the United States

Despite a 41% increase in the number of hospices since 2000, more than 60% of Americans die without hospice care. Given that hospice care is predominantly home based, proximity to a hospice is important in ensuring access to hospice services. We estimated the proportion of the population living in communities within 30 and 60 minutes driving time of a hospice. We conducted a cross-sectional study of geographic access to U.S. hospices using the 2008 Medicare Provider of Services data, U.S. Census data, and ArcGIS software. We used multivariate logistic regression to identify gaps in hospice availability by community characteristics. As of 2008, 88% of the population lived in communities within 30 minutes and 98% lived in communities within 60 minutes of a hospice. Mean time to the nearest hospice was 15 minutes and the range was 0 to 403 minutes. Community characteristics independently associated with greater geographic access to hospice included higher population density, higher median income, higher educational attainment, higher percentage of black residents, and the state not having a Certificate of Need policy. The percentage of each state's population living in communities more than 30 minutes from a hospice ranged from 0% to 48%. Recent growth in the hospice industry has resulted in widespread geographic access to hospice care in the United States, although state and community level variation exists. Future research regarding variation and disparities in hospice use should focus on barriers other than geographic proximity to a hospice.

Compassionate Accommodation after the Declaration of Brain Death

than blacks with no DNR (95% CI 1⁄4 1.94e2.09). Additionally, ten percent incremental increases in a NHs proportion of Medicaid-pay residents reduces the odds of hospice use by 44% among blacks (95% CI 1⁄4 0.56e0.57), but reduces the odds of hospice use among whites by less than one percent (95% CI 1⁄4 0.992e0.999). V. Conclusion. Individualand facility-level factors are associated with racial disparities in hospice use among NH decedents. VI. Implications for Research, Policy, or Practice. Heightening use of advanced directives and increasing hospice outreach to married blacks and low resource NHs could alleviate racial disparities in end-of-life care.

Ethnic Disparities in Hospice Use Among Asian‐American and Pacific Islander Patients Dying with Cancer

Asian Americans and Pacific Islanders (AAPIs) are a rapidly growing population in the United States, yet little is known about hospice use and length of stay in hospice of older AAPIs dying with cancer. A retrospective study was conducted of the last year of life of AAPI and white Medicare beneficiaries registered in the Surveillance, Epidemiology, and End Results Program. White (n=175,467) and AAPI (n=8,614) patients aged 65 and older who were dying with lung, colorectal, breast, prostate, gastric, or liver cancer were studied. Cox proportional hazards models were used to examine hospice use and length of stay in hospice. All AAPI subgroups studied had lower rates of hospice use (Chinese (adjusted hazard ratio (HR)=0.62, 95% confidence interval (CI)=0.55-0.69), Japanese (adjusted HR=0.67, 95% CI=0.60-0.73), Filipino (adjusted HR=0.61, 95% CI=0.54-0.70), Hawaiian/Pacific Islanders (adjusted HR=0.78, 95% CI=0.67-0.91), and other Asians (adjusted HR=0.70), 95% CI=0.55-0.90) than white patients, adjusting for patient demographic and clinical characteristics. Of those who enrolled in hospice (approximately 20% of the total sample), Japanese Americans had a shorter median length of stay (21 days), and Filipino Americans had a longer median length of stay (32 days) than white patients (26 days). Overall, approximately 20% of patients enrolled within 7 days of death, and only 6% had hospice stays that were longer than 2 months, with no significant differences across racial or ethnic groups. In conclusion, in every ethnic subgroup studied, AAPIs were less likely than whites to enroll in hospice. Further research is needed to understand these differences and eliminate potential barriers to hospice care.