Evaluation of Racial Disparities in Hospice Use and End-of-Life Treatment Intensity in the REGARDS Cohort

Key Points Question Are there differences between Black and White patients in the use of hospice and intensity of end-of-life treatment? Findings In this cohort study of 1212 decedents, Black individuals were significantly less likely to use hospice and more likely to have multiple emergency department visits and hospitalizations and undergo intensive treatment in the last 6 months of life compared with White individuals regardless of cause of death. Meaning Despite the increase in the use of hospice care in recent decades, racial disparities in the use of hospice care and the intensity of end-of-life treatment remain.


Introduction
Consistent with patient preferences to avoid intensive hospital-based care at the end of life, 1,2 in 2017, most US patients died at home. 3 Use of hospice care is on the rise in the United States-with most deaths of Medicare beneficiaries occurring while receiving hospice care, a significant increase in the last decade. 4 The fastest-growing segment of the population receiving hospice care includes individuals with noncancer diagnoses. 5 Despite the potential benefits of hospice enrollment for individuals and families, including enhanced quality of life for patients near the end of life [6][7][8] and decreased Medicare costs, 9 half of patients with terminal illnesses still do not use hospice care. 10 Furthermore, most individuals who use hospice care are admitted very close to the end of life. Short hospice stays (Յ3 days) have increased to 28.4% of all hospice stays, 10 and 14.3% of patients with cancer who enroll in hospice do so in the last 3 days of life. 11 In addition, high-intensity treatments at the end of life remain common despite patient preferences to avoid such care. For example, among Medicare beneficiaries, intensive care unit use in the last month of life increased from 24% in 2000 to 29% in 2015. 4 Research has documented racial differences in hospice use and end-of-life treatment intensity, consistent with a broad range of racial disparities in health care use and health outcomes. In general, Black decedents receive more aggressive care, have higher end-of-life health care spending, and are less likely to use hospice services than White decedents. [12][13][14] Reasons for these disparities include preferences for more aggressive care, mistrust of the health care system, lack of in-home resources, and miscommunication and misunderstanding of treatment options. 15 Because substantial shifts in end-of-life health care delivery have occurred, it is critical to better understand whether similar racial differences persist in the setting of different diseases. We used the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study linked to Medicare claims data to examine disparities in end-of-life care among individuals who have died of stroke, heart disease, cancer, dementia, or other serious illnesses. We hypothesized that high-intensity treatments at the end of life will be more common among Black than White decedents and that Black decedents will be less likely to use hospice care regardless of the cause of death.

Data Sources and Study Population
The data for this study are from REGARDS, an ongoing population-based cohort study of racial and regional differences in stroke mortality, with oversampling of Black individuals and residents of Southeastern states in the United States. The recruitment, enrollment, and assessment procedures of this national, population-based study are described in detail elsewhere. 16 17 and examined in previous analyses of health care use. 18,19 The REGARDS participants who died between January 1, 2013, and December 31, 2015, were included in this study, and the study was reviewed and approved by the institutional review boards of the University of Alabama at Birmingham and Johns Hopkins University. This report followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. 20

Outcome Measures
Our primary outcomes of interest were hospice use and other measures of end-of-life treatment intensity within the last 6 months of life. 21 All outcome variables were derived from Medicare fee-forservice (parts A and B) claims files. We focused on hospice use of 3 or more days as our primary measure to avoid capturing suboptimal hospice use owing to short duration. 7 Next, building on previous work, [22][23][24] we identified the use of 1 or more intensive life-sustaining medical procedures as determined by a review of International Classification of Diseases, Ninth Revision (ICD-9) codes or

International Statistical Classification of Diseases and Related Health Problems, Tenth Revision
(ICD-10) codes in each decedent's Medicare claims. These procedures included intubation and mechanical ventilation, tracheostomy, gastrostomy tube insertion, enteral or parenteral nutrition, hemodialysis, and cardiopulmonary resuscitation. Finally, we counted the number of emergency department (ED) admissions and inpatient hospitalizations in the 6-month period before death. Our primary focus was 2 or more ED visits and 2 or more hospital stays.

Main Exposure
Race in REGARDS is determined by self-report. Because the REGARDS study was designed to examine the factors that might explain the increased stroke mortality previously observed for Black individuals, only Black individuals and White individuals, who served as the reference group, were enrolled, and individuals who self-identified as Hispanic, Latino, Asian, or other races/ethnicities were excluded.

Covariates
Cause of death in the REGARDS study is adjudicated by an expert panel of clinicians using methods that are consistent with American Heart Association consensus guidelines. 25,26 Death certificates, autopsy reports, and medical records from hospitalizations in the last 6 months of life were retrieved.
Participant proxies (next of kin, family members, or close friends) were also interviewed to obtain information about the events surrounding the death. Each death is adjudicated independently by 2 expert clinicians who conduct their reviews using all information available at the time of review, including the participant's clinical baseline characteristics, death certificates, proxy interviews, the National Death Index, and medical records from recent hospital admissions. After individual review, the adjudicators agree on the underlying cause of death. Disagreements are resolved by consensus.
Because of our interest in the decision to use hospice services, we excluded individuals who were determined by the adjudication panel to have experienced sudden death or death due to unnatural causes (10.8% [146 of 1358] of all deaths). For the present analyses, we grouped cause of death into the following 4 categories: cancer (all types); dementia; cardiovascular disease (CVD), including myocardial infarction, heart failure, stroke, and pulmonary embolism; and other, which included causes such as end-stage kidney disease, liver disease, infection, respiratory disease, and other medical problems not considered to be sudden deaths.
Demographic variables (sex, date of birth, marital status, annual household income, and educational level) were collected from a computer-assisted telephone interview conducted by trained interviewers at the time of enrollment into REGARDS. Location of residence was categorized based on census region and whether it was in the southern "stroke belt" region of the United States and Louisiana] with high stroke mortality). The Charlson Comorbidity Index score was calculated using ICD-9 and ICD-10 diagnosis codes from the inpatient, outpatient, and physician claim (carrier) files for the 6-month period preceding death. These codes were then mapped to 17 comorbid conditions, weights were assigned, and the index was calculated. 19 Medicaid dual-eligibility status was obtained from the Medicare beneficiary enrollment file.

Statistical Analysis
Initial analyses were conducted in March 2019, and final primary analyses were conducted in February 2020. Based on a conceptual framework of treatment intensity for patients with serious illness 27 and a review of the literature, we first compared key clinical and demographic characteristics and markers of end-of-life treatment intensity by race. We used the χ 2 test, the t test, and the Wilcoxon rank sum test as appropriate. After stratifying by cause of death, we examined racial differences in markers of end-of-life treatment intensity. Next, we used multivariable logistic regression to examine the association of race with each of 4 outcomes: (1) hospice use of 3 or more days, (2) multiple (Ն2) ED visits in the last 6 months of life, (3) multiple (Ն2) hospital stays in the last 6 months of life, and (4) any use of intensive treatments in the last 6 months of life. Each model was adjusted for cause of death, sex, marital status, educational level, income, Charlson Comorbidity Index score, age at death, and Medicaid status. We also tested for interactions by race and cause of death for each outcome. SAS statistical software version 9.4 was used for all analyses (SAS Institute), and P < .05 was considered statistically significant. All tests were 2-tailed.

Results
We Decedents who died prior to 2013 were excluded owing to the unavailability of data on hospice use.
Furthermore, decedents in REGARDS with no Medicare claims or who were enrolled only in Medicare part C were excluded. Among the 1358 REGARDS participants who died during the period from 2013 to 2015 with Medicare fee for service (parts A and B coverage) in the last 6 months of life, we further excluded 83 who had adjudicated sudden cause of death (eg, cardiac sudden deaths) and 54 who died owing to an accident, injury, suicide, or homicide. Among the remaining 1221 decedents, we excluded 9 with an undetermined cause of death and included 1212 with cause-of-death adjudication in the present analyses (eFigure in the Supplement).
As shown in Table 1 After stratifying by cause of death, we found substantial racial differences in treatment intensity among those with CVD deaths (Figure). Although there were no significant differences in hospice use, Black participants who died of CVD were significantly more likely than White decedents to have more than 1  did not observe statistically significant racial differences in treatment intensity among any indicators.
Among participants whose cause of death was dementia, there was no significant difference in hospice use, ED visits, or hospitalizations by race, although Black decedents were significantly more likely to undergo intensive procedure use (6 of 37 [16.2%] vs 2 of 78 [2.6%]).
Our covariate-adjusted models are summarized in Table 3. Of primary interest is the association of race with outcomes after adjusting for covariates. Significant racial differences were found for all

Discussion
Consistent with Brown et al, 28 we documented extensive racial differences in end-of-life treatment, with Black decedents receiving less hospice care and having more ED visits, hospitalizations, and intensive treatments in the 6 months immediately preceding death compared with White decedents.
Although these findings remained even when we accounted for cause of death and other clinical and demographic characteristics in the analysis, we found that racial differences in treatment intensity were especially pronounced among those with noncancer diagnoses.
Although this study was not able to assess whether treatment-intensity measures were aligned with patient and family care treatment preferences, we know that most individuals report that they want less invasive care at the end of life. 2,29 Several possible explanations may underlie the higher intensity of care received by Black decedents in our study. First, other studies have documented that lack of trust in the medical system by Black patients is associated with a reduced willingness to forgo life-sustaining measures 30,31 and an increased use of the ED for usual care. 32 Second, poor communications between Black patients and health care professionals are documented and may be associated with differences in the intensity of health care service use. 33,34 In addition, cultural and spiritual differences may play an important in role in choosing to forgo life-sustaining procedures. 35 Black decedents may also have less access to higher-quality end-of-life care, including engagement in advance care planning in part owing to lower health literacy. 36 Our study afforded us the opportunity to examine racial differences in the context of rigorously ascertained causes of death. Consistent with other findings, 37 underlying cause of death was strongly associated with hospice use after controlling for other factors. Persons without cancer were far less likely to use hospice care relative to individuals with a cancer-related cause of death. Several possible explanations exist for the observed discrepancy in hospice use based on underlying cause of death.
Health care professionals who provide care for many common noncancer illnesses may lack awareness about the utility of hospice services. Low use of hospice care by patients without cancer may also be associated with poor prognostic accuracy for many common noncancer illnesses, such as CVD or dementia. Cancer trajectories are more predictable than noncancer disease trajectories. 38 Thus, it is easier for physicians to prognosticate when the life expectancy of a patient with cancer is 6 months or less, a criterion for hospice enrollment under the Medicare Hospice Benefit. Among cancer deaths, in fact, we did not find any racial differences in any marker of treatment intensity we examined, which suggests that the use of hospice care and more supportive care services may be more widely disseminated among those with advanced cancer, possibly reflecting the increased emphasis on end-of-life care for patients with cancer in the US health care system in recent years.
Among decedents with dementia, we did not find any differences in hospice use, but we still saw a significant increase in the use of life-sustaining procedures among Black patients, a particularly troublesome finding given the lack of utility of these procedures at the end of life for this population. 39,40 Despite an increased use of hospice care in the United States, there is a continued use of highintensity treatments at the end of life, 41 and significant differences by race and cause of death remain. 3 Efforts to reduce disparities in the quality of end-of-life care must be prioritized. In particular, targeted efforts to increase advance care planning among Black and other racial minority populations should be expanded. 42 The recent Centers for Medicare & Medicaid Services regulation to reimburse physicians and others for advance care planning discussions is another important step toward that goal. 43 Reducing the stigma of hospice use through education and community outreach is critical. 44,45 In particular, reducing disparities in hospice use in populations with noncancer causes of death will require improved prognostication, better patient-clinician communication, and rethinking current hospice outreach and enrollment practices. 46,47 Using this national study with oversampling of Black participants, we had a large population to examine racial differences in end-of-life care. Furthermore, we had expert adjudication of the underlying cause of death and, hence, could examine differences in hospice use and other treatments by cause of death. We also included a marker of income. Disproportionate socioeconomic disadvantage is associated with some, but not all, of the differences in health care intensity at the end of life by race. 28 Although our study was able to detect differences by race, larger studies are required to better examine interactions by race, educational level, and cause of death to understand the mechanisms by which disparities may exist.

Limitations
Our findings should be interpreted with a number of potential limitations in mind. We were limited to decedents with Medicare (in particular, those who had fee-for-service Medicare 6 months before death). Those excluded were younger, more likely to be Black, and had lower income. Our results therefore may not be generalizable to all decedents. Although we were able to identify deaths due to cancer, CVD, and dementia, our dementia decedent subgroup was too small to capture meaningful differences. This group in particular requires further study given the growing prevalence of persons living with dementia and the need for better treatment at the end of life, including appropriate hospice care use. Dementia may also have been underdiagnosed in our sample of patients who did not have routine cognitive testing, 48 with differential diagnosis by race. In addition, we grouped together multiple causes of death as "other illness." Although we examined differences between Black and White decedents, we were unable to examine other racial groups that were excluded by design in REGARDS. Our work regarding differences in care may still be applicable to other disadvantaged populations. Furthermore, while we included careful adjustment of variables in models, there may still be residual confounding. Finally, we did not have detailed information on patient and family treatment preferences, whether treatment was concordant with care received, prognostic uncertainty, or overall satisfaction with the care received. These factors are likely to vary by disease status and should be explored further.

Conclusions
Our work suggests that Black decedents undergo more intensive treatments at the end of life and are less likely to use hospice services relative to White decedents. More sustained efforts must be made to reduce disparities in end-of-life care through efforts to better educate and train health care professionals and to promote the discussion of personal values and treatment preferences for the end of life in Black populations.