title: Disparities in hospice care among older women dying with ovarian cancer.
abstract: BACKGROUND
  Timely hospice referral is an essential component of quality end-of-life care, although a growing body of research suggests that for patients with various types of cancer, hospice referrals often occur very late in the course of care, and are marked by sociodemographic disparities. However, little is known about the ovarian cancer patient population specifically. We examined the extent and timing of hospice referrals in ovarian cancer patients over age 65, and the factors associated with these outcomes.
  
  
  METHODS
  We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify 8211 women aged 66+ with ovarian cancer who were diagnosed between 2001 and 2005 and died by December 31, 2007. We excluded women who were not eligible for Medicare A continuously during the 6 months prior to death. Outcomes studied included overall hospice use in the last 6 months of life and late hospice enrollment, defined as within 3 days of death. We examined variations in these two measures based on year of diagnosis and sociodemographic characteristics (age, race, marital status, rural residence, income, education) and type of Medicare received (fee-for-service vs. managed care).
  
  
  RESULTS
  Among 8211 women in the cohort who died from ovarian cancer, 39.7% never received hospice care (3257/8211). Overall hospice care increased over the period of observation, from 49.7% in 2001 to 63.6% [corrected] in 2005, but the proportion of women receiving hospice care within 3 days of death did not improve. Among those who received hospice care, 11.2% (556/4954) and 26.2% (1299/4954) received such care within 3 and 7 days of death, respectively. A higher proportion of black women (46.5% vs. 38.4% among whites), women in the lowest income group (42.8% vs. 37.0% in the highest income group), and those receiving fee-for-service Medicare (41.3% vs.33.5% for women in managed care) never received hospice care. In multivariable models, factors associated with lack of hospice care included age younger than 80 years (OR 1.27, 95% CI 1.15-1.40), non-white race (OR 1.44, 95% CI 1.26-1.65), low income (OR 1.17, 95% CI 1.04-1.32) and enrollment in fee-for-service Medicare compared with managed care (OR 1.39, 95% CI 1.24-1.56).
  
  
  CONCLUSIONS
  More older women with ovarian cancer are receiving hospice care over time, however, a substantial proportion receive such care very near death, and sociodemographic disparities in hospice care exist. Our data also support the need to target lower-income and minority women in efforts to increase optimally timed hospice referrals in this population. Our finding that ovarian cancer patients enrolled in managed care plans were more likely to receive hospice care suggests the importance of health care system factors in the utilization of hospice services.
authors.affiliation: Center of Outcomes Research and Evaluation, Maine Medical Center Research Institute, ME, USA. fairfk@mmc.org
authors.forename: Kathleen M
authors.initials: KM
authors.lastname: Fairfield
authors.forename: Kimberly M
authors.initials: KM
authors.lastname: Murray
authors.forename: Heidi R
authors.initials: HR
authors.lastname: Wierman
authors.forename: Paul K J
authors.initials: PK
authors.lastname: Han
authors.forename: Sarah
authors.initials: S
authors.lastname: Hallen
authors.forename: Susan
authors.initials: S
authors.lastname: Miesfeldt
authors.forename: Edward L
authors.initials: EL
authors.lastname: Trimble
authors.forename: Joan L
authors.initials: JL
authors.lastname: Warren
authors.forename: Craig C
authors.initials: CC
authors.lastname: Earle
mesh_terms: D001741:Black or African American; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D005260:Female; D006299:Health Services for the Aged / Q000706:statistics & numerical data* / Q000639:trends; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D017051:Hospice Care / Q000706:statistics & numerical data* / Q000639:trends; D006801:Humans; D016015:Logistic Models; D006278:Medicare / Q000706:statistics & numerical data; D008913:Minority Groups; D010051:Ovarian Neoplasms / Q000208:ethnology / Q000401:mortality / Q000628:therapy*; D011203:Poverty; D012017:Referral and Consultation / Q000706:statistics & numerical data / Q000639:trends; D012042:Registries; D012959:Socioeconomic Factors; D013997:Time Factors; D014481:United States