Original Article
Comparison of Hospice Use by European Americans, African Americans, and Latinos: A Follow-Up Study
American Journal of Hospice & Palliative Medicine® 2015, Vol. 32(2) 205-209 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909113511143 ajhpm.sagepub.com
Merydawilda Colo´n, PhD, MPhil, MSW, LSW1, and Jennifer Lyke, PhD1
Abstract This study investigated the rate of hospice use by Latinos and African Americans relative to their prevalence in the general population between 2004 and 2010 as a follow-up to a previous investigation. Archival data (N ¼ 2625) were collected on patients’ race/ ethnicity, gender, marital status, length of stay in hospice, and reason for discharge. In contrast to previous findings, African Americans were more likely to utilize hospice services, but Latinos were less likely to use hospice services compared to the other groups. There were no differences among the racial/ethnic groups in terms of length of stay or disposition at termination. Strengthening efforts to reach a larger racial/ethnic representation in hospice programs may increase the rate of hospice use by some racial/ethnic groups but not others. Keywords hospice, palliative care, African American, Latino, demographics, Asian
Introduction Hospice services meet particular needs for dying patients and their families. These services are used by people who need support and assistance in the end stages of life, primarily patients diagnosed with cancer and other terminal diseases. The hospice philosophy embraces the provision of compassionate, palliative medical care and supportive services to patients and their families. Patients arrive at hospice through various pathways, such as referral by physicians, nursing homes, friends, or relatives; and the success of hospice treatment depends on multiple factors, especially patient characteristics, treatment provider characteristics, and the match between them. Many studies have established racial and ethnic disparities in health care1,2 and have pointed out that there are differences in how different groups utilize health care services.3,4 Patient characteristics are an integral part of any medical treatment process, and several researchers have investigated the role of ethnicity in hospice care. In general, investigators have drawn the conclusion that Latinos and African Americans are underrepresented in hospice programs due to barriers such as language difficulties,5-7 beliefs about health care, lower referral rates, lack of insurance,5,6 caregiver requirements, and cultural and religious differences.5-8(pp188-189) In a study comparing the rate of hospice utilization by European Americans, African Americans, and Latinos in a southern New Jersey hospice program, we found African Americans and Latinos used hospice at a significantly lower
rate than European Americans, between the years 1995 and 2001.8(pp187-188) In addition, African Americans’ use of hospice declined significantly during that time period, while European Americans’ use increased. Differences were also found among European Americans, African Americans, and Latinos in regard to variables that impact hospice administration and services such as marital status, living situation, caregiver, referral source, and payment method.8(pp188-189) Since we reported our findings in 2003, the National Hospice and Palliative Care Organization has made efforts to raise awareness about hospice services within ethnic groups. This follow-up study investigated the rate of hospice use by Latinos and African Americans relative to their prevalence in the general population between 2004 and 2010. It was expected that African Americans’ and Latinos’ use of hospice care would have increased relative to their prevalence in the general population compared to our previous findings.8(pp184-187) This study also compared characteristics of European Americans, African Americans, and Latinos that impact hospice administration and services such as age, marital status, living situation, religion, and language.
1
The Richard Stockton College of New Jersey, Galloway, NJ, USA
Corresponding Author: Merydawilda Colo´n, PhD, MPhil, MSW, LSW, Richard Stockton College of New Jersey, 101 Vera King Farris Drive, Galloway, NJ 08205, USA. Email: [email protected]
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Methods
Table 1. Ethnicity of Total Sample Compared to Census Data.
Sample Archival data were collected from the same community-based hospice serving 3 counties in southern New Jersey from which data were collected for our previous study published in 2003.8(p183) Data were collected on all patients who used hospice care between the years 2004 and 2010. Information on patients’ race/ethnicity, city of residence, religion, gender, marital status, primary language, length of stay in hospice, and reason for discharge was collected. The total sample of 2625 patients contained 1513 women (57.6%) and 1103 men (42%), with 9 patients (0.3%) missing data. The number of European American, African American, Latino, and Asian patients were 1999 (76.2%), 305 (11.6%), 81 (3.1%), and 37 (1.4%), respectively. The remaining 203 (7.7%) patients were from other ethnic backgrounds and were eliminated from further analyses. Patients’ ages ranged from 0 to 108 years with a mean age of 76.01 (standard deviation [SD] ¼ 14.62). Length of stay in hospice ranged from 0 to 2365 days with a mean of 44.37 (SD ¼ 103.84). The sample was 37.2% widowed, 33.3% married, 10.1% single, 5.8% divorced, 0.8% separated, and 0.6% life partnered, with 12.3% of the patients of unknown marital status. Data were also gathered on where the patients died or the disposition of the case at termination. In all, 89% of the sample died in hospice, 0.1% were hospitalized, 6% revoked services, and 4.7% were discharged.
Ethnicity European Americans African Americans Latinos Asians Total
Raw number
Percentage of sample
Expected Percentage of Samplea
1999 305 81 45 2430
82.26 12.55 3.33 1.85 100.00
79.69 7.06 10.08 3.17 100.00
a
According to weighted 2010 census data.
Figure 1. Number of deaths per year by racial/ethnic group.
Analyses These variables were then examined for differences between European American, African American, Latino, and Asian patients. First, the proportion of each racial/ethnic group was compared to census data in the same 3 New Jersey counties during that time period. A chi-square analysis was used to compare the numbers of European Americans, African Americans, Latinos, and Asians in the sample to the expected numbers based on the proportions of these groups in the general population. The expected numbers of patients from each ethnic group were calculated using data for each of the 3 counties provided by the US Census Bureau Census 20109 and weighting these values according to their county populations. Next, the data were broken down by year to examine trends in patient ethnicity across the years for which data were collected. A chi-square analysis was performed on the number of deaths per year from each racial/ethnic group to identify trends during the 2004 to 2010 time period. Finally, analyses of variance (ANOVAs) were performed to determine whether there were significant differences between European Americans, African Americans, Latinos, and Asians in terms of age or length of stay in hospice. Chi-square analyses were used to compare gender, marital status, and disposition at termination among these groups. In both ANOVA and chisquare analyses, post hoc analyses were performed as necessary.
Results Rate of Use When the ethnic breakdown of the total sample was compared to the census data (Table 1) from the year 2010 for Atlantic, Cape May, and Ocean counties, significant differences were found in the rate of hospice use among European Americans, African Americans, Latinos, and Asians compared to the prevalence of these groups in the general population, w2(3, n ¼ 2430) ¼ 228.863, P < .001. Follow-up tests indicated significant differences in the frequency of each of the four racial groups compared to their frequency in the county population. Specifically, African Americans were more likely to utilize hospice services than European Americans, Latinos, or Asians compared to their prevalence in the county populations, w2(1, n ¼ 2430) ¼ 80.08, p < .001; w2(1, n ¼ 386) ¼ 227.85, p < .001; and w2(1, n ¼ 350) ¼ 53.86, p < .001, respectively. Latinos were less likely to utilize hospice services compared to European Americans and Asians, w2(1, n ¼ 2080) ¼ 112.06, p < .001, and w2(1, n ¼ 126) ¼ 9.57, P < .01, respectively. Finally, European Americans and Asians did not differ significantly in their likelihood of utilizing hospice services (see Table 1). Comparing the 4 ethnic/racial groups over time, a chi-square analysis did not identify any significant trends across the years
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Colo´n and Lyke
70 60
Percentage
50 40 Male Female
30 20 10 0 European American
African American
Latino
Percentage of Racial/Ethnic Group
207
Asian
Racial/Ethnic Group
60 50 40 European American African American Latino Asian
30 20 10 0
Single
Married or Separated Widowed Life Partner or Divorced Marital Status
Figure 2. Percentages of males and females among racial/ethnic groups.
Figure 3. Percentages of racial/ethnic groups by marital status.
Table 2. Frequency of Marital Status of Hospice Patients by Racial/ Ethnic Group.
Table 3. Means and Standard Deviations for Ages of Racial/Ethnic Groups.
Ethnicity European Americans African Americans Latinos Asians Total
Married or life Single Partner 163 70 19 8 260
760 64 31 17 872
Separated or divorced
Widowed
124 35 5 3 167
826 106 16 7 955
2
for which data were collected, w (18, n ¼ 2422) ¼ 25.60, P > .05 (see Figure 1).
Gender Females were significantly more likely than males to utilize hospice services compared to their prevalence in the county populations, w2(1) ¼ 37.68, P < .0001. According to the census data for the relevant counties, 48% of the population were male and 52% were female. However, 58% of the hospice sample were male and 42% were female. In addition, there were significant differences in the ratio of males to females among the racial/ethnic groups, w2(3, n ¼ 2414) ¼ 20.62, P < .001. African Americans had a significantly higher ratio of females to males than all other groups, European Americans: w2(1, n ¼ 2296) ¼ 7.07, P < .01; Latinos: w2(1, n ¼ 384) ¼ 16.62, P < .001; Asians: w2(1, n ¼ 340) ¼ 7.14, P < .01. Latinos also had a significantly higher male to female ratio than European Americans, w2(1, n ¼ 2074) ¼ 9.03, P < .01, but did not differ from Asians, w2(1, n ¼ 118) ¼ .07, P > .05. European Americans and Asians did not differ significantly in their male to female ratios, w2(1, n ¼ 2030) ¼ 3.06, P > .05 (see Figure 2).
Marital Status A chi-square test revealed significant differences in marital status among hospice patients of different racial/ethnic
Racial/Ethnic Group
Mean
SD
European American African American Latino Asian American
77.63 69.79 62.52 68.3
13.56 17.28 16.53 12.08
Abbreviation: SD, standard deviation.
Table 4. Means and Standard Deviations for Length of Stay for Racial/ Ethnic Groups. Racial/Ethnic Group
Mean
SD
European American African American Latino Asian
46.69 41.07 34.54 27.92
109.47 79.63 55.62 47.61
Abbreviation: SD, standard deviation.
backgrounds, w2(9, n ¼ 2254) ¼ 122.48, P < .001. European Americans were least likely to be single or separated and most likely to be widowed. Asians were most likely to be married or have a life partner. African Americans were most likely to be separated or divorced. Latinos were most likely to be single and least likely to be married or have a life partner (see Table 2 and Figure 3).
Age A 1-way ANOVA indicated significant differences in the ages of hospice patients from various racial/ethnic backgrounds, F3, 2418 ¼ 56.52, P < .001. Post hoc tests (least significant difference) indicated European American hospice patients were significantly older than any of the other 3 racial/ethnic groups. African Americans were also significantly older than Latinos but did not differ significantly in age from Asians. Asians were also significantly older than Latinos (see Table 3).
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Length of Stay A 1-way ANOVA indicated there was no difference between racial/ethnic groups in terms of their length of stay in hospice, F3, 2418 ¼ 0.92, P > .05 (see Table 4).
Disposition at Termination A chi-square analysis indicated no difference in disposition at termination for patients from different racial/ethnic groups, w2(12, n ¼ 2601) ¼ 16.34, P > .05.
Discussion This study investigated the rate of hospice use by Latinos and African Americans relative to their prevalence in the general population between 2004 and 2010. It was predicted that African Americans’ and Latinos’ use of hospice would have increased relative to their prevalence in the general population compared to our previous findings.8(pp183-187) Findings confirmed this hypothesis for African Americans but not for Latinos. In our sample of 2430, African Americans were more likely to utilize hospice services than European Americans, Latinos, or Asians compared to their prevalence in the general population. This is an important finding that contradicts our previous research8(p185) in which both African Americans and Latinos used hospice at a significantly lower rate than European Americans. This finding also contradicts the lower rate of hospice use that Ramey and Chin10 found in a literature review of studies about African Americans with cancer. Moreover this finding differs from national trends in the use of hospice by African Americans. According to estimates by the National Hospice and Palliative Care Organization,11 of the total population of patients who received hospice services in 2011, 8.5% were African Americans. While in this study, 12.55% of the sample were African Americans compared to 7.06% of the population in the counties examined. Another finding was that Latinos were less likely to utilize hospice services compared to European Americans and Asians. This result is consistent with our previous findings8(pp184-187) and provides support for the implication that more needs to be done to increase Latinos’ representation in hospice programs. Despite hospice organizations’ efforts to reach out to Latinos,12 this ethnic group remains underrepresented in the hospice population. Among the estimated 1.65 million patients who received hospice care in 2011, 6.2% were Latinos.11(p7) In this study, 3.3% of the sample were Latinos compared to 10.08% of the population in the counties examined. This percentage is low considering that the Latino population increased from 35.3 million in 2000 to 50.5 million or 16% in 2010.13 The representation of Asians in this sample was a finding that differs from our 2003 study8(pp182-190) in which Asians were not represented in the sample. Although their representation was low (1.4%), their rate of hospice use was not significantly less than the rate of hospice use by European Americans. Furthermore, their representation is similar to national
estimates. The National Hospice and Palliative Care Organization11(p7) shows 2.4% of the total population of patients who received hospice services in 2011 were Asian, Hawaiian, and other Pacific Islander. Another interesting finding was disposition of the case at termination. In this study, 55% of the sample died at home, 18.4% died in a facility, and there were no significant differences in disposition at termination for patients from different racial/ethnic groups. This result indicates a need to offer inpatient hospice services for those who cannot stay in their residence at the end of life. As found in research about acculturation and attitudes of Latinos toward hospice ‘‘ . . . 11.1% would prefer to use hospice but not in their home.’’14(p238) The hospice from which data were drawn does not have an inpatient hospice program, and this may have implications for the low representation of Latinos. Results about the age of the sample were also important. In this study, there were significant differences in the age of hospice patients from different racial/ethnic groups. Europeans Americans were significantly older than any of the other 3 racial/ethnic groups. African Americans were significantly older than Latinos. Results showed Latinos were the youngest. This finding is interesting in light of Latinos’ low rate of hospice use and studies that have shown age among variables related to hospice knowledge.14(p237),15 For instance, Colo´n14(p241) found that Latinos who knew about the word ‘‘hospice’’ were older, had more years of education, and a higher household income than those who did not know about it. Therefore, hospice programs need to tailor marketing strategies to reach all age groups, levels of education, and income. Since our previous study,8(pp182-190) hospice programs in southern New Jersey have strengthened efforts to reach a larger ethnic representation in their patient population by actively visiting health care facilities conducting in services to inform health care providers and the community about hospice services. The National Hospice and Palliative Care Organization has also continued to raise awareness about hospice. Given that lack of awareness of hospice services has been found to contribute to the underuse of hospice by African Americans,16 it is likely that efforts to raise awareness have contributed to the increase in the rate of hospice use by African Americans in this study. This was an important finding and the first in the literature to show African Americans were more likely to use hospice services than European Americans, Latinos, or Asians compared to their prevalence in the county populations examined. The representation of Asians in this sample might also be attributed to efforts by southern New Jersey hospice programs to reach a larger ethnic representation in their patient population and to the National Hospice and Palliative Care Organization education initiatives.
Directions for Future Research The findings of this study provide support for the implication that strengthening efforts to reach a larger racial/ethnic representation in hospice programs may increase the rate of hospice
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use by racial/ethnic groups. Future research should focus on marketing strategies used by hospice programs to attract ethnic groups and outcomes of strategies implemented. Diversity factors such as age, income, education, language, immigration status, religion, and culture might be influencing the rate of hospice use by African Americans, Latinos, and Asians. Marketing strategies that take into account diversity factors need to be implemented, and research is needed to investigate the interplay of these factors in the rate of hospice use by racial/ ethnic groups. Major strengths of this study are the large sample size and that the sample was drawn from a hospice that serves a racially/ethnically diverse geographic area. However, the sample did not contain many Latinos or Asians and therefore conclusions with respect to these groups are tentative. Furthermore, the sample was from 1 specific hospice in New Jersey, and generalizations of the findings to other geographical areas are limited. Future research should expand to explore patterns of hospice use in additional hospice programs. This study showed a positive change in the rate of hospice use by African Americans relative to their prevalence in the general population. Nonetheless, racial/ethnic disparities in the rate of hospice use continue, and it is important to be vigilant of trends and their meaning in the context of end-of-life care and the demographics of the general population. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References 1. Aday L. At risk in America: The Health and Health Care Needs of Vulnerable Populations in the United States. 2nd ed. San Francisco, CA: Jossey-Bass; 2001. 2. Institute of Medicine of the National Academies. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: National Academies Press; 2002.
3. Evangelista LS, Dracup K, Doering LV. Racial differences in treatment seeking delays among heart failure patients. J Card Fail. 2002;8(6):381-386. 4. Weinick RM, Jacobs EA, Cacari Stone L, Ortega AN, Burstin H. Hispanic healthcare disparities: challenging the myth of a monolithic Hispanic population. Med Care. 2004;42(4):313-320. 5. Carrio´n IV. When do Latinos use hospice services? Studying the utilization of hospice services by Hispanics/Latinos. Soc Work Health Care. 2010;49(3):197-210. 6. Krakauer EL, Crenner C, Fox K. Barriers to optimum end-of-life care for minority patients. J Am Geriatr Soc. 2002;50(1):182-190. 7. Randall H, Csikai E. Issues affecting utilization of hospice services by rural Hispanics. J Ethn Cult Divers Soc Work. 2003; 12(2):79-94. 8. Colo´n M, Lyke J. Comparison of hospice use and demographics among European Americans, African Americans, and Latinos. Am J Hosp Palliat Care. 2003;20(3):182-190. 9. US Census Bureau: State and County Quick Facts. http://quick facts.census.gov/qfd/index.html. 2010. Accessed June 20 2013. 10. Ramey SJ, Chin SH. Disparity in hospice utilization by African American patients with cancer. Am J Hosp Palliat Care. 2012; 29(5):346-354. 11. National Hospice, & Palliative Care Organization. NHPCO Facts and Figures: Hospice Care in America. http://www.nhpco.org/ sites/default/files/public/Statistics_Research/2012_Facts_Figures. pdf. 2012. Accessed July 27, 2013. 12. National Hospice and Palliative Care Organization. NHPCO’s Caring connections Latino outreach guide. http://www.caringinfo.org/ files/public/outreach/Latino_Outreach_Guide.pdf. 2006-2007. Acc essed July 27, 2013. 13. US Census Bureau. The hispanic population: 2010 (C2010BR-04). 2011. URL: http://www.census.gov/prod/cen2010/briefs/c2010br04.pdf. Accessed July 6 2013. 14. Colo´n M. Acculturation and attitudes of Latinos toward hospice. J Soc Work End Life Palliat Care. 2012;8(3):229-248. 15. Richman JM, Rosenfeld LB. Demographic profile of individuals with knowledge of the hospice concept: Who is more likely to use hospice services? Am J Hosp Care. 1988;5(1):36-39. 16. Washington KT, Bickel-Swenson D, Stephens N. Barriers to hospice use among African Americans: a systematic review. Health Soc Work. 2008;33(4):267-274.
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Comparison of Hospice Use by European Americans, African Americans, and Latinos: A Follow-Up Study
American Journal of Hospice & Palliative Medicine® 2015, Vol. 32(2) 205-209 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909113511143 ajhpm.sagepub.com
Merydawilda Colo´n, PhD, MPhil, MSW, LSW1, and Jennifer Lyke, PhD1
Abstract This study investigated the rate of hospice use by Latinos and African Americans relative to their prevalence in the general population between 2004 and 2010 as a follow-up to a previous investigation. Archival data (N ¼ 2625) were collected on patients’ race/ ethnicity, gender, marital status, length of stay in hospice, and reason for discharge. In contrast to previous findings, African Americans were more likely to utilize hospice services, but Latinos were less likely to use hospice services compared to the other groups. There were no differences among the racial/ethnic groups in terms of length of stay or disposition at termination. Strengthening efforts to reach a larger racial/ethnic representation in hospice programs may increase the rate of hospice use by some racial/ethnic groups but not others. Keywords hospice, palliative care, African American, Latino, demographics, Asian
Introduction Hospice services meet particular needs for dying patients and their families. These services are used by people who need support and assistance in the end stages of life, primarily patients diagnosed with cancer and other terminal diseases. The hospice philosophy embraces the provision of compassionate, palliative medical care and supportive services to patients and their families. Patients arrive at hospice through various pathways, such as referral by physicians, nursing homes, friends, or relatives; and the success of hospice treatment depends on multiple factors, especially patient characteristics, treatment provider characteristics, and the match between them. Many studies have established racial and ethnic disparities in health care1,2 and have pointed out that there are differences in how different groups utilize health care services.3,4 Patient characteristics are an integral part of any medical treatment process, and several researchers have investigated the role of ethnicity in hospice care. In general, investigators have drawn the conclusion that Latinos and African Americans are underrepresented in hospice programs due to barriers such as language difficulties,5-7 beliefs about health care, lower referral rates, lack of insurance,5,6 caregiver requirements, and cultural and religious differences.5-8(pp188-189) In a study comparing the rate of hospice utilization by European Americans, African Americans, and Latinos in a southern New Jersey hospice program, we found African Americans and Latinos used hospice at a significantly lower
rate than European Americans, between the years 1995 and 2001.8(pp187-188) In addition, African Americans’ use of hospice declined significantly during that time period, while European Americans’ use increased. Differences were also found among European Americans, African Americans, and Latinos in regard to variables that impact hospice administration and services such as marital status, living situation, caregiver, referral source, and payment method.8(pp188-189) Since we reported our findings in 2003, the National Hospice and Palliative Care Organization has made efforts to raise awareness about hospice services within ethnic groups. This follow-up study investigated the rate of hospice use by Latinos and African Americans relative to their prevalence in the general population between 2004 and 2010. It was expected that African Americans’ and Latinos’ use of hospice care would have increased relative to their prevalence in the general population compared to our previous findings.8(pp184-187) This study also compared characteristics of European Americans, African Americans, and Latinos that impact hospice administration and services such as age, marital status, living situation, religion, and language.
1
The Richard Stockton College of New Jersey, Galloway, NJ, USA
Corresponding Author: Merydawilda Colo´n, PhD, MPhil, MSW, LSW, Richard Stockton College of New Jersey, 101 Vera King Farris Drive, Galloway, NJ 08205, USA. Email: [email protected]
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American Journal of Hospice & Palliative Medicine® 32(2)
206
Methods
Table 1. Ethnicity of Total Sample Compared to Census Data.
Sample Archival data were collected from the same community-based hospice serving 3 counties in southern New Jersey from which data were collected for our previous study published in 2003.8(p183) Data were collected on all patients who used hospice care between the years 2004 and 2010. Information on patients’ race/ethnicity, city of residence, religion, gender, marital status, primary language, length of stay in hospice, and reason for discharge was collected. The total sample of 2625 patients contained 1513 women (57.6%) and 1103 men (42%), with 9 patients (0.3%) missing data. The number of European American, African American, Latino, and Asian patients were 1999 (76.2%), 305 (11.6%), 81 (3.1%), and 37 (1.4%), respectively. The remaining 203 (7.7%) patients were from other ethnic backgrounds and were eliminated from further analyses. Patients’ ages ranged from 0 to 108 years with a mean age of 76.01 (standard deviation [SD] ¼ 14.62). Length of stay in hospice ranged from 0 to 2365 days with a mean of 44.37 (SD ¼ 103.84). The sample was 37.2% widowed, 33.3% married, 10.1% single, 5.8% divorced, 0.8% separated, and 0.6% life partnered, with 12.3% of the patients of unknown marital status. Data were also gathered on where the patients died or the disposition of the case at termination. In all, 89% of the sample died in hospice, 0.1% were hospitalized, 6% revoked services, and 4.7% were discharged.
Ethnicity European Americans African Americans Latinos Asians Total
Raw number
Percentage of sample
Expected Percentage of Samplea
1999 305 81 45 2430
82.26 12.55 3.33 1.85 100.00
79.69 7.06 10.08 3.17 100.00
a
According to weighted 2010 census data.
Figure 1. Number of deaths per year by racial/ethnic group.
Analyses These variables were then examined for differences between European American, African American, Latino, and Asian patients. First, the proportion of each racial/ethnic group was compared to census data in the same 3 New Jersey counties during that time period. A chi-square analysis was used to compare the numbers of European Americans, African Americans, Latinos, and Asians in the sample to the expected numbers based on the proportions of these groups in the general population. The expected numbers of patients from each ethnic group were calculated using data for each of the 3 counties provided by the US Census Bureau Census 20109 and weighting these values according to their county populations. Next, the data were broken down by year to examine trends in patient ethnicity across the years for which data were collected. A chi-square analysis was performed on the number of deaths per year from each racial/ethnic group to identify trends during the 2004 to 2010 time period. Finally, analyses of variance (ANOVAs) were performed to determine whether there were significant differences between European Americans, African Americans, Latinos, and Asians in terms of age or length of stay in hospice. Chi-square analyses were used to compare gender, marital status, and disposition at termination among these groups. In both ANOVA and chisquare analyses, post hoc analyses were performed as necessary.
Results Rate of Use When the ethnic breakdown of the total sample was compared to the census data (Table 1) from the year 2010 for Atlantic, Cape May, and Ocean counties, significant differences were found in the rate of hospice use among European Americans, African Americans, Latinos, and Asians compared to the prevalence of these groups in the general population, w2(3, n ¼ 2430) ¼ 228.863, P < .001. Follow-up tests indicated significant differences in the frequency of each of the four racial groups compared to their frequency in the county population. Specifically, African Americans were more likely to utilize hospice services than European Americans, Latinos, or Asians compared to their prevalence in the county populations, w2(1, n ¼ 2430) ¼ 80.08, p < .001; w2(1, n ¼ 386) ¼ 227.85, p < .001; and w2(1, n ¼ 350) ¼ 53.86, p < .001, respectively. Latinos were less likely to utilize hospice services compared to European Americans and Asians, w2(1, n ¼ 2080) ¼ 112.06, p < .001, and w2(1, n ¼ 126) ¼ 9.57, P < .01, respectively. Finally, European Americans and Asians did not differ significantly in their likelihood of utilizing hospice services (see Table 1). Comparing the 4 ethnic/racial groups over time, a chi-square analysis did not identify any significant trends across the years
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Colo´n and Lyke
70 60
Percentage
50 40 Male Female
30 20 10 0 European American
African American
Latino
Percentage of Racial/Ethnic Group
207
Asian
Racial/Ethnic Group
60 50 40 European American African American Latino Asian
30 20 10 0
Single
Married or Separated Widowed Life Partner or Divorced Marital Status
Figure 2. Percentages of males and females among racial/ethnic groups.
Figure 3. Percentages of racial/ethnic groups by marital status.
Table 2. Frequency of Marital Status of Hospice Patients by Racial/ Ethnic Group.
Table 3. Means and Standard Deviations for Ages of Racial/Ethnic Groups.
Ethnicity European Americans African Americans Latinos Asians Total
Married or life Single Partner 163 70 19 8 260
760 64 31 17 872
Separated or divorced
Widowed
124 35 5 3 167
826 106 16 7 955
2
for which data were collected, w (18, n ¼ 2422) ¼ 25.60, P > .05 (see Figure 1).
Gender Females were significantly more likely than males to utilize hospice services compared to their prevalence in the county populations, w2(1) ¼ 37.68, P < .0001. According to the census data for the relevant counties, 48% of the population were male and 52% were female. However, 58% of the hospice sample were male and 42% were female. In addition, there were significant differences in the ratio of males to females among the racial/ethnic groups, w2(3, n ¼ 2414) ¼ 20.62, P < .001. African Americans had a significantly higher ratio of females to males than all other groups, European Americans: w2(1, n ¼ 2296) ¼ 7.07, P < .01; Latinos: w2(1, n ¼ 384) ¼ 16.62, P < .001; Asians: w2(1, n ¼ 340) ¼ 7.14, P < .01. Latinos also had a significantly higher male to female ratio than European Americans, w2(1, n ¼ 2074) ¼ 9.03, P < .01, but did not differ from Asians, w2(1, n ¼ 118) ¼ .07, P > .05. European Americans and Asians did not differ significantly in their male to female ratios, w2(1, n ¼ 2030) ¼ 3.06, P > .05 (see Figure 2).
Marital Status A chi-square test revealed significant differences in marital status among hospice patients of different racial/ethnic
Racial/Ethnic Group
Mean
SD
European American African American Latino Asian American
77.63 69.79 62.52 68.3
13.56 17.28 16.53 12.08
Abbreviation: SD, standard deviation.
Table 4. Means and Standard Deviations for Length of Stay for Racial/ Ethnic Groups. Racial/Ethnic Group
Mean
SD
European American African American Latino Asian
46.69 41.07 34.54 27.92
109.47 79.63 55.62 47.61
Abbreviation: SD, standard deviation.
backgrounds, w2(9, n ¼ 2254) ¼ 122.48, P < .001. European Americans were least likely to be single or separated and most likely to be widowed. Asians were most likely to be married or have a life partner. African Americans were most likely to be separated or divorced. Latinos were most likely to be single and least likely to be married or have a life partner (see Table 2 and Figure 3).
Age A 1-way ANOVA indicated significant differences in the ages of hospice patients from various racial/ethnic backgrounds, F3, 2418 ¼ 56.52, P < .001. Post hoc tests (least significant difference) indicated European American hospice patients were significantly older than any of the other 3 racial/ethnic groups. African Americans were also significantly older than Latinos but did not differ significantly in age from Asians. Asians were also significantly older than Latinos (see Table 3).
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Length of Stay A 1-way ANOVA indicated there was no difference between racial/ethnic groups in terms of their length of stay in hospice, F3, 2418 ¼ 0.92, P > .05 (see Table 4).
Disposition at Termination A chi-square analysis indicated no difference in disposition at termination for patients from different racial/ethnic groups, w2(12, n ¼ 2601) ¼ 16.34, P > .05.
Discussion This study investigated the rate of hospice use by Latinos and African Americans relative to their prevalence in the general population between 2004 and 2010. It was predicted that African Americans’ and Latinos’ use of hospice would have increased relative to their prevalence in the general population compared to our previous findings.8(pp183-187) Findings confirmed this hypothesis for African Americans but not for Latinos. In our sample of 2430, African Americans were more likely to utilize hospice services than European Americans, Latinos, or Asians compared to their prevalence in the general population. This is an important finding that contradicts our previous research8(p185) in which both African Americans and Latinos used hospice at a significantly lower rate than European Americans. This finding also contradicts the lower rate of hospice use that Ramey and Chin10 found in a literature review of studies about African Americans with cancer. Moreover this finding differs from national trends in the use of hospice by African Americans. According to estimates by the National Hospice and Palliative Care Organization,11 of the total population of patients who received hospice services in 2011, 8.5% were African Americans. While in this study, 12.55% of the sample were African Americans compared to 7.06% of the population in the counties examined. Another finding was that Latinos were less likely to utilize hospice services compared to European Americans and Asians. This result is consistent with our previous findings8(pp184-187) and provides support for the implication that more needs to be done to increase Latinos’ representation in hospice programs. Despite hospice organizations’ efforts to reach out to Latinos,12 this ethnic group remains underrepresented in the hospice population. Among the estimated 1.65 million patients who received hospice care in 2011, 6.2% were Latinos.11(p7) In this study, 3.3% of the sample were Latinos compared to 10.08% of the population in the counties examined. This percentage is low considering that the Latino population increased from 35.3 million in 2000 to 50.5 million or 16% in 2010.13 The representation of Asians in this sample was a finding that differs from our 2003 study8(pp182-190) in which Asians were not represented in the sample. Although their representation was low (1.4%), their rate of hospice use was not significantly less than the rate of hospice use by European Americans. Furthermore, their representation is similar to national
estimates. The National Hospice and Palliative Care Organization11(p7) shows 2.4% of the total population of patients who received hospice services in 2011 were Asian, Hawaiian, and other Pacific Islander. Another interesting finding was disposition of the case at termination. In this study, 55% of the sample died at home, 18.4% died in a facility, and there were no significant differences in disposition at termination for patients from different racial/ethnic groups. This result indicates a need to offer inpatient hospice services for those who cannot stay in their residence at the end of life. As found in research about acculturation and attitudes of Latinos toward hospice ‘‘ . . . 11.1% would prefer to use hospice but not in their home.’’14(p238) The hospice from which data were drawn does not have an inpatient hospice program, and this may have implications for the low representation of Latinos. Results about the age of the sample were also important. In this study, there were significant differences in the age of hospice patients from different racial/ethnic groups. Europeans Americans were significantly older than any of the other 3 racial/ethnic groups. African Americans were significantly older than Latinos. Results showed Latinos were the youngest. This finding is interesting in light of Latinos’ low rate of hospice use and studies that have shown age among variables related to hospice knowledge.14(p237),15 For instance, Colo´n14(p241) found that Latinos who knew about the word ‘‘hospice’’ were older, had more years of education, and a higher household income than those who did not know about it. Therefore, hospice programs need to tailor marketing strategies to reach all age groups, levels of education, and income. Since our previous study,8(pp182-190) hospice programs in southern New Jersey have strengthened efforts to reach a larger ethnic representation in their patient population by actively visiting health care facilities conducting in services to inform health care providers and the community about hospice services. The National Hospice and Palliative Care Organization has also continued to raise awareness about hospice. Given that lack of awareness of hospice services has been found to contribute to the underuse of hospice by African Americans,16 it is likely that efforts to raise awareness have contributed to the increase in the rate of hospice use by African Americans in this study. This was an important finding and the first in the literature to show African Americans were more likely to use hospice services than European Americans, Latinos, or Asians compared to their prevalence in the county populations examined. The representation of Asians in this sample might also be attributed to efforts by southern New Jersey hospice programs to reach a larger ethnic representation in their patient population and to the National Hospice and Palliative Care Organization education initiatives.
Directions for Future Research The findings of this study provide support for the implication that strengthening efforts to reach a larger racial/ethnic representation in hospice programs may increase the rate of hospice
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use by racial/ethnic groups. Future research should focus on marketing strategies used by hospice programs to attract ethnic groups and outcomes of strategies implemented. Diversity factors such as age, income, education, language, immigration status, religion, and culture might be influencing the rate of hospice use by African Americans, Latinos, and Asians. Marketing strategies that take into account diversity factors need to be implemented, and research is needed to investigate the interplay of these factors in the rate of hospice use by racial/ ethnic groups. Major strengths of this study are the large sample size and that the sample was drawn from a hospice that serves a racially/ethnically diverse geographic area. However, the sample did not contain many Latinos or Asians and therefore conclusions with respect to these groups are tentative. Furthermore, the sample was from 1 specific hospice in New Jersey, and generalizations of the findings to other geographical areas are limited. Future research should expand to explore patterns of hospice use in additional hospice programs. This study showed a positive change in the rate of hospice use by African Americans relative to their prevalence in the general population. Nonetheless, racial/ethnic disparities in the rate of hospice use continue, and it is important to be vigilant of trends and their meaning in the context of end-of-life care and the demographics of the general population. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
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