Spousal Characteristics and Older Adults' Hospice Use: Understanding Disparities in End-of-Life Care

Abstract

Background: Hospice use has been shown to benefit quality of life for patients with terminal illness and their families, with further evidence of cost savings for Medicare and other payers. While disparities in hospice use by patient diagnosis, race, and region are well documented and attention to the role of family members in endof-life decision-making is increasing, the influence of spousal characteristics on the decision to use hospice is unknown. Objectives: To determine the association between spousal characteristics and hospice use. Design: We used data from the Health and Retirement Study (HRS), a prospective cohort study, linked to the Dartmouth Atlas of Health Care and Medicare claims. Setting: National study of 1567 decedents who were married or partnered at the time of death (2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011). Measures: Hospice use at least 1 day in the last year of life as measured via Medicare claims data. Spousal factors (e.g., education and health status) measured via survey. Results: In multivariate models controlling for patient factors and regional variation, spouses with lower educational attainment than their deceased spouse had decreased likelihood of hospice use (odds ratio [OR] = 0.58; 95% confidence interval [CI] = 0.40-0.82). Health of the spouse was not significantly associated with likelihood of decedent hospice use in adjusted models. Implications: Although the health of the surviving spouse was not associated with hospice use, their educational level was a predictor of hospice use. Spousal and family characteristics, including educational attainment, should be examined further in relation to disparities in hospice use. Efforts to increase access to high-quality end-of-life care for individuals with serious illness must also address the needs and concerns of caregivers and family.

Hospice Utilization in the United States: A Prospective Cohort Study Comparing Cancer and Noncancer Deaths

“…We used data from the HRS, a nationally representative longitudinal cohort survey of older adults in the United States with biennial data collection. 24,25 HRS researchers initially used a national probability proportionate to size sampling approach that began with selection at the county level. 26 Black and Hispanic individuals were oversampled to ensure adequate representation of minority groups.…”

Going It Alone: Advance Directive Discordance in Older Married Couples

“…Higher education increases the odds of engaging in written ACP (Boerner et al, 2013; Koss & Baker, 2018; Rao et al, 2014). Unlike age, health status, and race/ethnicity, we treated education as a pooled marital resource because the education of each spouse, especially the husband’s, often influences both spouses’ financial status, health, and decision-making (Brown, Hummer, & Hayward, 2014; Crystal, Shea, & Krishnaswami, 1992; Koss, 2017; Ornstein et al, 2016). Individuals with higher education may seek information about ACP more proactively (Smith, Dixon, Trevena, Nutbeam, & McCaffery, 2009).…”

Frequency and Risk Factors for Live Discharge from Hospice

“…Socio‐demographic characteristics, including race/ethnicity and socioeconomic status, have wide ranging consequences for health and healthcare access, and have been shown to affect knowledge and attitudes about hospice care . Further, caregiver and spousal characteristics have also been shown to influence hospice use and end‐of‐life decision making . Younger patients and those without advance directives may have preferences for life‐sustaining treatments, and thus be more likely to electively revoke hospice benefits .…”