Hospice Use and In-Hospital Death among Nursing Home Residents: Evidence of Racial Disparities?

Racial disparities in hospice use and hospitalization at the end-of-life (EOL), in nursing homes (NH), were reported. Blacks are less likely to use hospice and more likely to die in hospitals, suggesting poorer EOL care. We examine whether differences in hospice use and in-hospital death between black and white residents are due to within- or across-facility disparities.

Study sample includes 47,759 long-term residents (9.91% black and 90.09% white) who died during 2005-2007 in 515 NHs in NYS. Medicare denominator, inpatient and hospice claims, and the MDS were linked with the OSCAR database. For each outcome (in-hospital death and hospice use) we fit both individual and random effect models.

Overall, 16.76% (11.44% black and 17.34% white) used hospice in the last 100 days of life and 25.80% of residents (40.74% black and 24.18% white) died in hospitals. Blacks are less likely to use hospice (OR=0.77, P<.0001) and more likely to die in hospitals (OR=1.38, P<.0001), controlling for individual risks. After accounting for NH random effects and organizational characteristics we found no effect of race on hospice use (OR=0.90, P=0.100) or in-hospital death (OR=0.93, P=0.134). Living in facilities with greater concentration of black residents increases the odds of in-hospital death (P<.0001), but not of hospice use.

Blacks and Whites residing in the same facility are equally likely to use hospice and die in-hospital. However, Blacks are more likely to reside in facilities with poorer quality of care as measured by high rates of in-hospital death and little or no hospice use.