Racial and ethnic disparities in hospice use after referral

The efficacy of hospice in providing high quality end-of-life care has been substantially demonstrated in the scientific literature. The problem, however, is that hospice is vastly under-utilized among the terminally ill and particularly among racial and ethnic minorities; and no known studies have examined factors associated with hospice use while adjusting for patients who never had the opportunity to enroll. The purpose of this study was two-fold: 1) to develop a conceptual model to explore, describe and predict hospice utilization using a variety of patient, contextual and institutional factors, and 2) to test the model among a cohort of patients who have been referred to hospice, regardless of their utilization outcome. The newly developed model, the Behavioral Model of Hospice Use, was used to guide the extraction of variables from the administrative databases of two non-profit hospice agencies located in central North Carolina. Logistic regression determined which variables predicted both hospice utilization and the reasons patients did not use hospice when applicable. The final sample consisted of 3,825 patients referred to hospice from 2003-2006. Non-Whites were 3.1 times less likely to use hospice after referral than Whites (p = .078); and, when patients were referred by a physician (as compared to other source), those referred by female physicians were 6.6 times more likely to use hospice after referral than patients referred by male physicians (p = .081). The results of this study suggest that the patient's race/ethnicity is important even after referral. However, patient race/ethnicity may not be as important as the characteristics of the referring physician, raising the question if the issue of under-utilization is not so much whether patients are referred at all but rather whether they are referred appropriately or by whom. The reasons for disparities in hospice use are more likely related to the characteristics of the institution and/or the referral process and not related to the characteristics of the patient. Future studies should expand on the Behavioral Model of Hospice Use by including additional concepts, such as the role of caregivers and individual beliefs and values related to end-of-life care