Impact of individual and market factors on the timing of initiation of hospice terminal care

CONTEXT. Hospice terminal care is now used by 10% to 15% of elderly Americans at variable points before their deaths. OBJECTIVE. By examining the duration of patient survival after enrollment in hospice care, we sought to identify individual and market factors associated with the timing of hospice use. DESIGN. We linked Medicare claims, census information, and Area Resource File data to form a national cohort of 151,410 hospice patients admitted in 1993 and followed up until late 1996. We examined this cohort with Cox regression and other means. MAIN OUTCOME MEASURE. The primary outcome measure was survival after hospice enrollment. RESULTS. The patients had a mean+/-SD age of 79.0+/-7.4 years; 10.2% were nonwhite; 51.4% were female; and 72.3% had cancer. Median survival after hospice enrollment was 30 days (interquartile range, 10-86 days). After adjustment for measured patient, provider, and market factors, several variables were associated with relatively earlier hospice enrollment, farther from death. Compared with complementary groups, nonwhites were enrolled in hospice 4 days earlier; women, 5 days earlier; older people, 1 day earlier; and those with substance abuse, psychiatric disease, or dementia, each 3 days earlier. After adjustment, income and education were not associated with the timing of enrollment. Patients residing in markets with more hospital beds, greater hospice capacity, or a higher proportion of generalists were enrolled earlier. CONCLUSIONS. Even after adjustment for certain clinical attributes, individual social factors and local market factors were associated with survival after hospice enrollment. Certain socially disadvantaged groups were enrolled earlier, as were those residing in areas with more medical institutions. The decision to enroll patients in hospice may depend on both nonclinical and clinical factors.