Identifying Drivers of Hospice Disparities for Older Adults With and Without Alzheimer’s Disease and Related Dementias: The Role of Hospice Markets
Funded Grant
Overview
Affiliation
View All
Overview
description
ABSTRACT Every year, 1.7 million older adults in the United States enroll in hospice, half of whom have Alzheimer's Disease or Related Dementias (ADRD). Despite hospice being considered the gold standard for end-of-life care, substantial disparities persist in hospice access, quality, and outcomes. While individual preferences partially explain disparities, they do not fully explain persistent disparities in hospice enrollment, receipt of care from lower-quality hospices, or hospice disenrollment. This study will examine the role of regional hospice market variation as a potential structural factor driving disparities. The hospice industry has seen major changes in recent years and emerging evidence suggests hospice market changes have varied regionally. Since 2010, the number of agencies has doubled to over 6000, ownership structures have shifted, and mergers and acquisitions are common. People with dementia may be especially susceptible to hospice market dynamics. Due to their slow decline and uncertain prognosis, people with dementia tend have much longer average stays in hospice, while their intensity of care needs tend to be lower. This may create organizational incentives that influence hospice enrollment practices, with implications for disparities. This study will examine the role of hospice market variation as a potential causal mechanism underlying disparities in hospice access and quality among older adults with and without ADRD. We will create novel county-level measures of hospice markets and link them to national Medicare data to evaluate how regional market variation is associated with disparities in hospice outcomes. We will also leverage California’s 2022 hospice moratorium as a natural experiment to examine whether a state public health intervention was associated with changes in hospice market characteristics and subsequent disparities in hospice outcomes. Aim 1 will characterize county-level hospice markets and assess characteristics of individuals who live in those markets. Aim 2 will use Within- Between Random Effects models to quantify the contribution of hospice market characteristics to disparities in hospice outcomes (any enrollment, enrollment in low-quality hospice, disenrollment). Aim 3 will use Differencein- Difference regression models to evaluate the effect of California's moratorium on disparities in hospice access and outcomes. This research will provide rigorous evidence on the extent to which hospice markets contribute to disparities in end-of-life care, directly informing public health approaches to reducing disparities. Additionally, the novel market measures will enable future research examining how organizational, market, patient, and health system factors interact to shape hospice access, quality, and outcomes. By identifying structural mechanisms underlying disparities in hospice care, this study will generate evidence to inform public health approaches to improve end-of-life care for all older adults.
