title: Race and residence: intercounty variation in black-white differences in hospice use.
abstract: BACKGROUND
  Although blacks use hospice at lower rates than whites in the U.S., racial differences in hospice use vary by geographic area.
  
  
  OBJECTIVE
  To describe intercounty variability in black-white differences in hospice use and the association with the supply of health care resources.
  
  
  METHODS
  Subjects were a retrospective cohort of Medicare beneficiaries in North and South Carolina who died in 2008. Using Wilcoxon tests and logistic regression, we examined the differences in the supply of health care resources (hospital beds and physicians per population age 65 years and older, percentage of generalists, etc.) between counties with and without racial disparity in hospice use. Counties with a racial disparity had significantly (P < 0.05) higher rates of hospice use among whites than blacks.
  
  
  RESULTS
  Of 76,283 decedents in 128 counties, 19.78% were black. In the 39 counties (30.47%) with racial disparity in hospice use, the mean proportion of whites who enrolled in hospice was 41.3% vs. 28.66% of blacks (P < 0.0001). Counties with more hospital beds per population age 65 years and older had a higher odds (OR, 1.39; 95% confidence interval [CI] 1.04-1.86) and those with a larger proportion of generalists had a lower odds (OR, 0.01; 95% CI 0.001-0.476) of having a racial disparity in hospice use.
  
  
  CONCLUSIONS
  In most counties, the rates of hospice use were similar for blacks and whites. In counties with a racial disparity, there were more resources to deliver aggressive care (i.e., hospital beds and specialists). Because of a greater preference for life-sustaining therapies, blacks may be more likely to use acute care services at the end of life when resources for the delivery of these services are readily available.
authors.affiliation: Department of Medicine, Duke University, Durham, USA; Division of Geriatrics, Duke University, Durham, USA; Center for the Study of Aging and Human Development, Duke University, Durham, USA; Center for Palliative Care, Duke University, Durham, USA; Geriatrics Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, North Carolina, USA. Electronic address: johns196@mc.duke.edu.
authors.forename: Kimberly S
authors.initials: KS
authors.lastname: Johnson
authors.forename: Maragatha
authors.initials: M
authors.lastname: Kuchibhatla
authors.forename: Richard
authors.initials: R
authors.lastname: Payne
authors.forename: James A
authors.initials: JA
authors.lastname: Tulsky
mesh_terms: D001741:Black or African American / Q000706:statistics & numerical data*; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D005260:Female; D017051:Hospice Care / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data*; D009657:North Carolina / Q000453:epidemiology; D012111:Residence Characteristics / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D013022:South Carolina / Q000453:epidemiology; D014481:United States; D014600:Utilization Review; D044465:White People / Q000706:statistics & numerical data*
keywords: Hospice; end-of-life care; geographic variation; health care disparities; race