Hospice Quality, Race, and Disenrollment in Hospice Enrollees With Dementia

Abstract

Background: Racial and ethnic minoritized people with dementia (PWD) are at high risk of disenrollment from hospice, yet little is known about the relationship between hospice quality and racial disparities in disenrollment among PWD. Objective: To assess the association between race and disenrollment between and within hospice quality categories in PWD. Design/Setting/Subjects: Retrospective cohort study of 100% Medicare beneficiaries 65+ enrolled in hospice with a principal diagnosis of dementia, July 2012-December 2017. Race and ethnicity (White/Black/Hispanic/Asian and Pacific Islander [AAPI]) was assessed with the Research Triangle Institute (RTI) algorithm. Hospice quality was assessed with the publicly-available Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey item on overall hospice rating, including a category for hospices exempt from public reporting (unrated). Results: The sample included 673,102 PWD (mean age 86, 66% female, 85% White, 7.3% Black, 6.3% Hispanic, 1.6% AAPI) enrolled in 4371 hospices nationwide. Likelihood of disenrollment was higher in hospices in the lowest quartile of quality ratings (vs. highest quartile) for both White (adjusted odds ratio [AOR] 1.12 [95% confidence interval 1.06-1.19]) and minoritized PWD (AOR range 1.2-1.3) and was substantially higher in unrated hospices (AOR range 1.8-2.0). Within both low- and high-quality hospices, minoritized PWD were more likely to be disenrolled compared with White PWD (AOR range 1.18-1.45). Conclusions: Hospice quality predicts disenrollment, but does not fully explain disparities in disenrollment for minoritized PWD. Efforts to improve racial equity in hospice should focus both on increasing equity in access to high-quality hospices and improving care for racial minoritized PWD in all hospices.

Keywords: dementia; disenrollment; health services; hospice quality; racial disparities.

FIG. 1.

Adjusted predicted probability of disenrollment by race and hospice quality. Hospice quality is assessed using the CAHPS survey for the proportion of respondents rating a hospice 9 or 10 out on a scale of 1–10, where 10 is best. Predicted probabilities are estimated using a multilevel mixed-effects model that includes a random intercept for hospice, fixed effects for hospice quality and race, an interaction term for hospice and race, and are adjusted for hospice case-mix (age, gender, insurance status, comorbidities, residence type, rurality, area deprivation, region) and hospice organizational characteristics (years in operation size, ownership, and proportion of dementia patients). AAPI, Asian and Pacific Islander; CAHPS, Consumer Assessment of Healthcare Providers and Systems.