Predictors of Length of Hospice Use Among Older Adults: The Role of Race/Ethnicity

Background and Purpose Although the optimal length of hospice service has not been defined, length of stay may be an indicator of the quality of care, with greater length of stay suggesting better quality of care. Therefore, referral sooner rather than later in a person's illness is preferable. Race/ethnicity has been associated with different patterns of hospice services. The purpose of this study was to examine factors associated with length of hospice service. In particular, the study assessed whether race/ethnicity modified any observed relationships between gender, primary caregiver, diagnosis, referral source, or payment type and the length of hospice service (i.e., time to death).

Methods The study included a total of 16,323 older patients (age 65 and older; Mage = 81.4, SD = 8.3) served by a hospice in Florida, during a four-year period, 2002-2006. Of these, 83.5% were Whites, 7.6% were African Americans, and 8.9% were Hispanics. Survival analyses were conducted using the Cox proportional hazards model in predicting the time to death. The interaction terms between race/ethnicity and other covariates were included in the model to test the modifying effects of race/ethnicity.

Results During the study period, 58.5% died. Compared to Whites with an average stay of 88 days (SD = 139.0), Hispanics stayed in the hospice longest (M = 99 days, SD = 145.5), followed by African Americans (M = 90 days, SD = 139.9). All study variables were significantly associated with time to death (p < .05). Women had a longer time in hospice service than men (HR = .80, CI = .77–.84). Persons referred from long-term care (LTC) settings had higher risks of death compared to those referred from physicians in other settings (HR = 1.29, CI = 1.20–1.38). Being an African American female was associated with a high risk of death (HR=1.21, CI=1.03–1.42). In addition, African Americans referred from LTC had a higher risk of death than those being referred by physicians in other settings (HR = 1.34, CI = 1.02–1.76), as were Hispanics referred from LTC (HR = 1.38, CI = 1.07–1.78).

Conclusions and Implications Results indicate that Whites had the highest risk of death (and hence the shortest hospice stays) compared to African Americans and Hispanics. It is important to note, however, that racial/ethnic minorities (especially African Americans) are considerably underrepresented in hospice settings. Social workers are significantly involved in improving quality of life for those at the end of life in both LTC and hospice settings. It is important for social workers to recognize who are at risk of being delayed for referral and thus of being deprived of hospice care that has the potential to improve their quality of life and care at the end of life.