Racial Disparities in Hospice Outcomes: A Race or Hospice-Level Effect?

Objectives: To determine whether there is racial variation in hospice enrollees in rates of hospitalization and hospice disenrollment and, if so, whether systematic differences in hospice provider patterns explain the variation. Design: Longitudinal cohort study. Setting: Hospice. Participants: Medicare beneficiaries (N = 145,038) enrolled in a national random sample of hospices (N = 577) from the National Hospice Survey and followed until death (2009–10). Measurements: We used Medicare claims data to identify hospital admissions, emergency department (ED) visits, and hospice disenrollment after hospice enrollment. We used a series of hierarchical models including hospice-level random effects to compare outcomes of blacks and whites. Results: In unadjusted models, black hospice enrollees were significantly more likely than white enrollees to be admitted to the hospital (14.9% vs 8.7%, odds ratio (OR) = 1.84, 95% confidence interval (CI) = 1.74–1.95), visit the ED (19.8% vs 13.5%, OR = 1.58, 95% CI = 1.50–1.66), and disenroll from hospice (18.1% vs 13.0%, OR = 1.48, 95% CI = 1.40–1.56). These results were largely unchanged after accounting for participant clinical and demographic covariates and hospice-level random effects. In adjusted models, blacks were at higher risk of hospital admission (OR = 1.75, 95% CI = 1.64–1.86), ED visits (OR = 1.61, 95% CI = 1.52–1.70), and hospice disenrollment (OR = 1.54, 95% CI = 1.45–1.63). Conclusion: Racial differences in intensity of care at the end of life are not attributable to hospice-level variation in intensity of care. Differences in patterns of care between black and white hospice enrollees persist within the same hospice.