Eligibility criteria contribute to racial disparities in hospice use

ATLANTA, Ga., 23 dec 2008 -- A new study finds that hospice services—care that is provided by physicians, visiting nurses, chaplains, home health aides, social workers and counselors—have restrictions that reduce usage by many patients who are most in-need, particularly African Americans. The research, published in the February 1, 2009 issue of CANCER, a peer-reviewed journal of the American Cancer Society, indicates that the eligibility criteria for hospice services should be reconsidered.

In order to enroll in hospice, patients must have a prognosis of six months or less if their illness runs its usual course. They must also accept the palliative nature of hospice care. African American patients are less likely than white patients to use hospice, but the reasons for this difference have remained somewhat unknown.

In the current work, investigators at the University of Pennsylvania designed a study to explore the reasons for racial disparities in hospice care among cancer patients. To define and compare preferences for cancer treatment and perceived needs for hospice services among African-American patients and white patients, Dr. David Casarett and colleagues interviewed 283 patients who were receiving cancer treatment at six oncology clinics within the University of Pennsylvania Cancer Network. Patients were asked about their perceived need for five hospice services and their preferences for continuing cancer treatment, and they were followed for six months or until death. The researchers theorized that if disparities in hospice use were the result of preference for aggressive treatment among African Americans, then their rates of hospice use could be increased by redesigning hospice eligibility criteria. Conversely, if African Americans were less likely to want hospice services, then changes to the benefit may not be necessary, but modifications to the services that are offered may be warranted.

Dr. Casarett's team found that African-American patients had stronger preferences for continuing their cancer treatments as well as greater perceived needs for hospice services. The greater perceived need for hospice services among African Americans was attributed largely to differences in self-reported finances—poorer patients wanted more services.

"These findings suggest that the hospice eligibility criteria of Medicare and other insurers requiring patients to give up cancer treatment contribute to racial disparities in hospice use," the authors wrote. "Moreover, these criteria do not select those patients with the greatest needs for hospice services," they added.

The basis for these disparities is likely related to both cultural differences and economic characteristics. The results from this study indicate that hospice access could be made fairer by using eligibility criteria that are more directly need-based. For example, the investigators suggested that eligibility might be determined by assessing needs for specific hospice services such as pain or symptom management.

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Article: "Race, treatment preferences, and hospice enrollment: Eligibility criteria may exclude patients with the greatest needs for care." Jessica Fishman, Peter O'Dwyer, Hien L. Lu, Hope Henderson, David A. Asch, and David J. Casarett. CANCER; Published Online: December 22, 2008 (DOI: 10.1002/cncr.24046); Print Issue Date: February 1, 2009.