Effect of Hospice Access on the Use of Hospice among Patients with Metastatic Breast Cancer

Great variation and high cost exist in treating terminally ill patients. Hospice provides an alternative palliative care for terminally ill patients. Previous studies have demonstrated that patients choosing hospice had increased end of life (EOL) quality and decreased EOL cost, especially for cancer patients. Breast cancer accounts for 23% of all cancer cases among women. However, only 28.9% of patients with breast cancer received hospice care before death. Hospice use has been reported to be associated with race, marital status, insurance type and income in previous studies. Yet these studies did not address whether hospice use is affected by the access to hospice by patients. If hospice access affects hospice use, hospice care may be underutilized in the areas where patients do not have adequate access to hospices, leading to less satisfied EOL care and increased cost. In this study, we examined the effects of hospice access on the use of hospice among women diagnosed with metastatic breast cancer (MBC). We used SEER-Medicare linked data to collect incident MBC cases and adopted a retrospective cohort design. Patients were selected if they were 66 years or older with MBC diagnosed between 1992 and 2002, and had continuous Medicare Part A and Part B coverage one year prior to the diagnosis and two years after diagnosis or until the date of death. 4433 MBC patients were identified. We calculated each patient's distance to the nearest hospice, the number of hospice and the number of hospice employees in a 50-mile radius around the patient's residence zip code. We used multivariate logistic regression to estimate the relationships between hospice access and use controlling for age, race, marital status, income, education, comorbidities, diagnosis years and SEER region. Our results demonstrated statistically significant lower hospice use by (1) patients living further from the closest hospice and (2) for those patients that live in areas with fewer hospices per capita. Our distance measure suggests that current hospice providers may be less willing to enroll patients farther from their offices. In addition, in areas with fewer hospices per capita hospices may be near capacity and have little incentive to reach out to additional terminally ill patients in their local area.