title: Hospice use among urban Black and White U.S. nursing home decedents in 2006.
abstract: OBJECTIVE
  Medicare hospice is a valuable source of quality care at the end of life, but its lower use by racial minority groups is of concern. This study identifies factors associated with hospice use among urban Black and White nursing home (NH) decedents in the United States.
  
  
  METHODS
  Multiple data sources are combined and multilevel logistic regression is utilized to examine hospice use among urban Black and White NH residents who had access to hospice and died in 2006 (N = 288,202).
  
  
  RESULTS
  In NHs, Blacks are less likely to use hospice than Whites (35.4% vs. 39.3%), even when controlling for covariates, interactions, and clustering of decedents in NHs and counties (adjusted odds ratio = 0.81, 95% confidence interval = 0.77-0.86). Variation in hospice use is greater among subgroups of Blacks than between Blacks and Whites, and these variations are predominantly due to individual-level factors, with some influence of NH-level factors. Hospice use is higher for Blacks versus Whites with do-not-resuscitate orders and lower for Blacks versus Whites with congestive heart failure (CHF). Additionally, hospice use is greater among Blacks with versus without do-not-resuscitate or do-not-hospitalize orders or cancer and those in low-tier versus other NHs. There was also lower hospice use among Blacks with versus without CHF.
  
  
  CONCLUSIONS
  Efforts to reduce racial differences in hospice use should attend to individual-level factors. Heightening use of advance directives and targeting Blacks with CHF for hospice could be particularly helpful.
authors.affiliation: Department of Community Health, Center for Gerontology and Health Care Research, Brown University, Providence, RI 02912, USA. michael_lepore@brown.edu
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Lepore
authors.forename: Susan C
authors.initials: SC
authors.lastname: Miller
authors.forename: Pedro
authors.initials: P
authors.lastname: Gozalo
mesh_terms: D016223:Advance Directives / Q000208:ethnology; D001741:Black or African American / Q000706:statistics & numerical data*; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D017051:Hospice Care / Q000706:statistics & numerical data*; D006738:Hospices / Q000706:statistics & numerical data*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008913:Minority Groups; D010342:Patient Acceptance of Health Care / Q000208:ethnology* / Q000706:statistics & numerical data; D012959:Socioeconomic Factors; D013727:Terminal Care; D014481:United States; D044465:White People / Q000706:statistics & numerical data*