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.