title: Are Hospice Admission Practices Associated With Hospice Enrollment for Older African Americans and Whites?
abstract: BACKGROUND
  Hospices that enroll patients receiving expensive palliative therapies may serve more African Americans because of their greater preferences for aggressive end-of-life care.
  
  
  OBJECTIVE
  Examine the association between hospices' admission practices and enrollment of African Americans and whites.
  
  
  METHODS
  This was a cross-sectional study of 61 North and South Carolina hospices. We developed a hospice admission practices scale; higher scores indicate less restrictive practices, that is, greater frequency with which hospices admitted those receiving chemotherapy, inotropes, and so forth. In separate multivariate analyses for each racial group, we examined the relationship between the proportion of decedents (age ≥ 65) served by a hospice in their service area (2008 Medicare Data) and admission practices while controlling for health care resources (e.g., hospital beds) and market concentration in the area, ownership, and budget.
  
  
  RESULTS
  Nonprofit hospices and those with larger budgets reported less restrictive admission practices. In bivariate analyses, hospices with less restrictive admission practices served a larger proportion of patients in both racial groups (P < 0.001). However, in the multivariate models, nonprofit ownership and larger budgets but not admission practices predicted the outcome.
  
  
  CONCLUSIONS
  Hospices with larger budgets served a greater proportion of African Americans and whites in their service area. Although larger hospices reported less restrictive admission practices, they also may have provided other services that may be important to patients regardless of race, such as more in-home support or assistance with nonmedical expenses, and participated in more outreach activities increasing their visibility and referral base. Future research should explore factors that influence decisions about hospice enrollment among racially diverse older adults.
authors.affiliation: Department of Medicine, Duke University, Durham, North Carolina, USA; Division of Geriatrics, Duke University, Durham, North Carolina, USA; Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA; Duke Palliative Care, Duke University, Durham, North Carolina, USA; Geriatrics Research, Education and Clinical Center, Veterans Affairs Medical Center, Durham, North Carolina, USA. Electronic address: kimberly.s.johnson@dm.duke.edu.
authors.forename: Kimberly S
authors.initials: KS
authors.lastname: Johnson
authors.affiliation: Department of Medicine, Duke University, Durham, North Carolina, USA; Division of Geriatrics, Duke University, Durham, North Carolina, USA; Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA; Duke Divinity School, Duke University, Durham, North Carolina, USA.
authors.forename: Richard
authors.initials: R
authors.lastname: Payne
authors.affiliation: Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA.
authors.forename: Maragatha N
authors.initials: MN
authors.lastname: Kuchibhatla
authors.affiliation: Department of Medicine, Duke University, Durham, North Carolina, USA; Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, USA; Duke Palliative Care, Duke University, Durham, North Carolina, USA; Division of General Internal Medicine, Duke University, Durham, North Carolina, USA; Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham, North Carolina, USA.
authors.forename: James A
authors.initials: JA
authors.lastname: Tulsky
mesh_terms: D001741:Black or African American / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D017051:Hospice Care / Q000191:economics / Q000379:methods* / Q000706:statistics & numerical data*; D006738:Hospices / Q000191:economics / Q000706:statistics & numerical data; D006760:Hospitalization / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D015999:Multivariate Analysis; D009657:North Carolina; D012424:Rural Population / Q000706:statistics & numerical data; D013022:South Carolina; D014505:Urban Population / Q000706:statistics & numerical data; D044465:White People / Q000706:statistics & numerical data*
keywords: African Americans; Hospice; end-of-life care; racial disparities