title: Targeted investment improves access to hospice and palliative care.
abstract: BACKGROUND
  Availability of hospice and palliative care is increasing, despite lack of a clear national strategy for developing and evaluating their penetration into and impact on the target population.
  
  
  OBJECTIVE
  To determine whether targeted investment (i.e., strategic grants made by one charitable foundation) in hospice and palliative care in one U.S. state (North Carolina [NC]) led to improved access to end-of-life care services as indicated by hospice utilization.
  
  
  METHODS
  Access was measured by the death service ratio (DSR), defined as the proportion of people who died and were served by hospice for at least one day before death. Calculation of the DSR is based on counts of patients accessing hospice by county in a given year (numerator) and U.S. Census projected population data for that county (denominator). Multilevel modeling was the primary analytic strategy used to generate two models: 1) comparison of the DSR in counties with vs. without philanthropic funding and 2) relationship between years since receipt of a philanthropic grant and DSR.
  
  
  RESULTS
  In NC, the average DSR increased from 20.7% in 2003 to 35.8% in 2009 (55% increase). In 2009, 82 of 100 NC counties had a DSR below the U.S. average (41.6%). In Model 1, significant associations were found between county population and DSR (P=0.03) and between receipt of philanthropic funding and DSR (P=0.01); on average, funded counties had a DSR that was 2.63 percentage points higher than unfunded counties.
  
  
  CONCLUSIONS
  Receipt of philanthropic funding appeared to be associated with improved access to palliative care and hospice services in NC.
authors.affiliation: Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina, USA; Department of Medicine, Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA. Electronic address: amy.abernethy@duke.edu.
authors.forename: Amy P
authors.initials: AP
authors.lastname: Abernethy
authors.forename: Janet
authors.initials: J
authors.lastname: Bull
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Whitten
authors.forename: Rebecca
authors.initials: R
authors.lastname: Shelby
authors.forename: Jane L
authors.initials: JL
authors.lastname: Wheeler
authors.forename: Donald H
authors.initials: DH
authors.lastname: Taylor
mesh_terms: D006297:Health Services Accessibility / Q000191:economics* / Q000706:statistics & numerical data; D017051:Hospice Care / Q000191:economics* / Q000706:statistics & numerical data*; D006801:Humans; D007449:Investments / Q000191:economics* / Q000706:statistics & numerical data; D009026:Mortality; D009657:North Carolina / Q000453:epidemiology; D010166:Palliative Care / Q000191:economics* / Q000706:statistics & numerical data*; D017149:Private Sector / Q000191:economics; D012923:Social Class; D015996:Survival Rate
keywords: Hospice; access; death service ratio; palliative care