Geographic Variation in Hospice Use Prior to Death

OBJECTIVES: To examine national variation in use of the Medicare hospice benefit by older individuals before their death, and to identify individual characteristics and local market factors associated with hospice use. DESIGN: Retrospective analysis of Medicare administrative data. SETTING: Hospice care. PARTICIPANTS: Older Medicare enrollees who died in 1996. MEASUREMENTS: Rate of hospice use per 1,000 older Medicare beneficiary deaths. RESULTS: Overall, 155 of every 1,000 older Medicare beneficiaries who die use hospice before death. This rate is significantly higher among younger older persons (P < .001), non-blacks (P < .001), persons living in wealthier areas (P < .001), and persons in urban areas (P < .001). Areas with a higher proportion of non-cancer diagnoses among hospice users have higher rates of hospice use for both cancer and non-cancer reasons than areas with a majority of hospice users having cancer diagnoses (P < .001). Hospice use is higher in areas with fewer hospital beds per capita (P < .001), areas with lower in-hospital death rates (P < .001), and areas with higher HMO enrollment (P < .001). Rates of hospice use are also positively related to average reimbursements for health care (P < .001) and to physicians per capita (P < .001). In the largest metropolitan statistical areas (MSAs), rates of hospice use vary more than 11-fold from a low of 35.15 (Portland, ME) to a high of 397.2 per 1,000 deaths (Ft. Lauderdale, FL). CONCLUSIONS: The wide variation in hospice use suggests that there is great potential to increase the number of users of the Medicare hospice benefit.