Disparities in healthcare access and quality are well-documented for African Americans and include not only disease prevention, early detection, and appropriate treatment but also end-of-life care. Compared to Whites, African Americans are more likely to experience poor quality care at the end of life, including inadequate pain management and poor provider communication, and to report lower overall satisfaction with the quality of end-of-life care. Also, older African Americans with advanced illness are less likely than Whites to enroll in hospice which is currently the most comprehensive model for the care of patients at the end-of-life. Hospice enrollment is associated with both improvements in multiple domains of care, including symptom management and provider communication, and reduced disparities between Whites and African Americans in the quality of end-of-life care. Therefore, increasing the use of hospice care by older African Americans may result in a greater likelihood of high quality, patient-centered end-of-life care for this vulnerable population. Like other healh disparities research, much of the literature on racial disparities in hospice use has focused on documenting the problem rather than seeking solutions. There is little empiric research identifying modifiable factors which may influence the use of hospice of care. Preliminary work suggests that hospice providers may be one target for interventions to increase access to hospice for older African Americans. This idea is supported by significant variability in the practices and policies of individual hospice providers beyond requirements for Medicare certification and the large variability across hospice service areas in the proportion of Medicare beneficiaries who enroll in hospice. This variability is even greater among African Americans and is not explained by decedent demographics or healthcare market factors. Additionally, although health care organizational culture is increasing being recognized as an important determinant of health disparities, much of the literature on organizational factors associated with the use of hospice by African Americans includes expert opinion of strategies that should work (i.e. community-based partnerships), but there have been no well- controlled analyses attempting to determine which of these strategies work best under which circumstances. The overall goal of this project is to identify modifiable practices of hospice providers that are associated with greater use of hospice care by older African Americans in their service area. Using a survey and qualitative interview of a national sample of hospice providers, the study's specific aims will examine the association between the admission policies, community outreach practices, and other organizational characteristics, such as staff diversity, goals and strategic planning of hospice providers and service to older African Americans in their service area. Understanding which organizational practices are associated with greater use of hospice by African Americans will inform the development of interventions to increase access to hospice care and improve the quality of end-of-life care.

Public Health Relevance

Despite higher mortality rates from a number of chronic illnesses and lower quality end-of-life care, African Americans use hospice services at lower rates that Whites. Hospice use is associated with improvements in the quality of end-of-life care. This research will identify the practices of hospice providers (i.e. community partnerships) which are associated with greater use of hospice care by older African Americans in their service area.

National Institute of Health (NIH)
National Institute on Aging (NIA)
Research Project (R01)
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Study Section
Health Disparities and Equity Promotion Study Section (HDEP)
Program Officer
Haaga, John G
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Duke University
Internal Medicine/Medicine
Schools of Medicine
United States
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Boucher, Nathan A; Kuchibhatla, Maragatha; Johnson, Kimberly S (2017) Meeting Basic Needs: Social Supports and Services Provided by Hospice. J Palliat Med 20:642-646
Rogers, Joseph G; Patel, Chetan B; Mentz, Robert J et al. (2017) Palliative Care in Heart Failure: The PAL-HF Randomized, Controlled Clinical Trial. J Am Coll Cardiol 70:331-341
Johnson, Kimberly S; Payne, Richard; Kuchibhatla, Maragatha N et al. (2016) Are Hospice Admission Practices Associated With Hospice Enrollment for Older African Americans and Whites? J Pain Symptom Manage 51:697-705