BLACK RACE IS ASSOCIATED WITH PREFERENTIAL USE OF HOSPICE AT HOME VERSUS AT A SKILLED NURSING FACILITY

Purpose: Hospice, which provides end of life care for more than 1/3 of Americans, can occur at home, a skilled nursing facility (SNF), or a dedicated hospice facility.  SNF-based hospice is thought to be the most expensive for patients as the Medicare benefit only covers the hospice care, not the SNF room and board.  Using a large, nationally representative database, we compared the selection of hospice venue by blacks and whites and examined whether blacks favor the less expensive hospice options.

Method: Using the 2007 the National Home and Hospice Care Survey (NHHCS), which surveyed 4705 patients discharged from hospice across the US, we developed a multinomial logistic regression evaluating the odds of a patient selecting hospice at home versus a dedicated facility and the odds of hospice at home versus a skilled nursing facility.  Race (black or white) was an independent variable in all regressions.  Covariates for the adjusted regression were selected based on clinical relevance to hospice venue selection.  In the NHHCS, blacks were older and less likely to have cancer.  They also had shorter enrollment periods in hospice and different distributions of hospice settings and primary insurance providers.

Result: Blacks (255 discharges), compared with whites (3514 discharges), were more likely to select home hospice, compared with SNF-based hospice in the unadjusted regressions (marginal effect = -0.12, p < 0.001.)  Following adjustment for demographic and clinical characteristics, black race remained a negative predictor of SNF-based hospice selected (marginal effect = -0.025, p = 0.034), though the effect was attenuated.  Other factors were also identified as predictors of home or SNF-based hospice use:  self pay and length of stay <7 days were both negative predictors of the SNF venue (marginal effect = 0.022, p = 0.018 and marginal effect -0.038, p< 0.001, respectively), while living alone was a positive predictor (marginal effect 0.032, p = 0.002).  Blacks and whites used home and dedicated inpatient hospice services equally in both the unadjusted and adjusted regressions.

Conclusion: Black hospice patients are more likely to receive hospice services at home, rather than at the more expensive venue of a skilled nursing facility, than white hospice patients.