Hospice use by Hispanic and non-Hispanic white cancer decedents

Health Services Research, August, 2004 by Nuha A. Lackan, Glenn V. Ostir, Jean L. Freeman, Yong-Fang Kuo, Dong D. Zhang, James S. Goodwin

Hospice services are typically used when aggressive therapy is no longer being sought and death is expected to occur within six months. The number of patients opting for this type of care is increasing. In the last decade, for example, the use of hospice services more than doubled among Medicare beneficiaries (General Accounting Office 2000; Lackan, Freeman, and Goodwin 2003; National Hospice and Palliative Care Organization 2002; Cassel and Field 1997).

A number of studies have examined differences in hospice use by patient ethnicity (McCarthy et al. 2003; Virnig et al. 1999a, 1999b, 2000, 2002; Lackan, Freeman, and Goodwin 2003; Christakis 1998; National Hospice and Palliative Care Organization 2002; Crawley et al. 2000; Neubauer and Hamilton 1990; Talamantes, Lawler, and Espino 1995; Haber 1999; Gelfand et al. 2001; Gordon 1995). Using 1990 Medicare claims data, Christakis and Escarce (1996) found nonwhites were significantly less likely to use hospice than whites. In a series of studies using 1992 (Virnig et al. 1999a, 1999b) and 1996 (Virnig et al. 2000) Medicare claims data, Virnig et al. found African Americans were significantly less likely to use hospice than non-African Americans. Similarly, using linked SEER-Medicare data, Asians and Pacific Islanders were found to be significantly less likely to use hospice care than non-Hispanic whites (Ngo-Metzger et al. 2003).

Several studies also suggest that Hispanics use hospice at significantly lower rates than non-Hispanic whites (McCuistion 1994; Pawling-Kaplan and O'Connor 1989; National Hospice and Palliative Care Organization 2002). However, these studies are few in number and are limited by small sample size or lack of denominator data.

In a previous study (Lackan, Freeman, and Goodwin 2003), we reported no differences in hospice use among four ethnic groups (non-Hispanic whites, African Americans, Hispanics, and Asian/Pacific Islanders). That study, however, was limited to older women with a diagnosis of breast cancer. Our current study will expand this research by examining hospice use in a sample including both men and women dying of breast, colorectal, lung, or prostate cancer in one of four SEER areas (Los Angeles, San Francisco, and San Jose--Monterey, California and the state of New Mexico) in which sample sizes in both ethnic groups are large enough to perform detailed statistical analyses.

The purpose of this study is to compare hospice use for Hispanics and non-Hispanic whites dying of cancer. We examine hospice use over time and identify correlates of hospice use.

METHODS

Data Sources

Data are from the linked Surveillance, Epidemiology and End Result (SEER)--Medicare database. The SEER program is a population-based registry for incident cancer cases in the United States maintained by the National Cancer Institute. SEER areas are located throughout the country and are selected on their ability to contribute accurate data to the registry and on their population composition. These areas included the states of Connecticut, Hawaii, Iowa, New Mexico, and Utah and the metropolitan areas of Detroit, San Francisco, Atlanta, Seattle, Los Angeles County, and San Jose-Monterey. The SEER areas cover approximately 14 percent of the United States population (Ries et al. 2000). The registries include data on all incident cancer cases. This information is obtained from hospitals, outpatient clinics, laboratories, private practitioners, nursing homes, hospices, death certificates, and autopsy reports. In addition, demographic information, including age, ethnicity, and sex, and tumor characteristics (such as size and stage) and course of treatment postdiagnosis are collected. Medicare claims for the present study are from the hospice standard analytic file (SAF). These claims were linked to the SEER registry data for cases aged 65 and older as part of a collaborative project between the National Cancer Institute and the Centers for Medicare and Medicaid Services (Warren et al. 2002). The project also created a Patient Entitlement and Diagnosis Summary File (PEDSF), which includes information on patient age, sex, marital status, managed care versus fee-for-service insurance, year of death, and cause of death.

Study Population

The sample included men and women age 67 or older at time of death to ensure that each subject had two full years of Medicare coverage prior to death. Only subjects classified by SEER as Hispanic or non-Hispanic white were included in the study sample. In order to ensure adequate sample sizes in both ethnic groups, only subjects residing in the four SEER areas of Los Angeles, San Francisco, San Jose-Monterey, and New Mexico were included in the sample. Subjects who were diagnosed with cancer before 1991 were excluded because the Los Angeles site was not added to the SEER program until that year. Only subjects who died of cancer were included in the analysis in order to increase the likelihood of hospice eligibility. A determination of death due to cancer was made by including only those decedents with International Classification of Diseases, 9th Revision codes for malignant neoplasms ranging from 141.0-239.9 (International Classification of Diseases, 9th revision, Clinical Modification) listed on state death certificates as the underlying cause of death.