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Ethnic Differences in Hospice Enrollment
Studies have documented the persisting lower rates of hospice enrollment among ethnic minority groups.[1, 2] Given the positive outcomes related to hospice enrollment,[3] investigating interventions that may reduce these disparities is critical.
Inpatient palliative care (IPC) programs were developed to improve pain and symptom management, provide patients with holistic and comprehensive prognosis and treatment options, and help patient and families clarify goals of care.[4] Although significant evidence of IPC program effectiveness in improving patient outcomes exists,[5] studies have not examined the ability of IPC programs to diminish ethnic disparities in access to hospice. We conducted a retrospective cohort study to determine if ethnic differences in hospice enrollment are experienced among patients following receipt of IPC consultation.
METHODS
A retrospective study was conducted in a nonprofit health maintenance organization medical center. The sample included seriously ill patients aged 65 years and over who received an IPC consultation and survived to hospital discharge. Data were collected from IPC databases, IPC consultation checklist (which included recording of code status discussion), and electronic medical records. The IPC team recorded discharge disposition including discharge to hospice care, home‐based palliative care (a standard program similar to hospice but offered for patients with an estimated prognosis of 1 year or less and without the caveat of foregoing curative care),[6] home with home healthcare, nursing facility, and home with standard outpatient care. Ethnicity was collected via patient report.
2 and t tests were conducted to compare those admitted to hospice with those who were not. We used logistic regression to determine the effects of ethnicity on enrollment in hospice, adjusting for demographics and clinical factors. We conducted analysis using IBM SPSS 19 (IBM, Armonk, NY).
FINDINGS
From 2007 to 2009, 408 patients received IPC consults and were subsequently discharged from the hospital. Forty‐four had missing data on ethnicity or discharge disposition, leaving 364 in the analytic sample. The mean age was 80.1 years (standard deviation [SD]=8.2), and 48.9% were female. The sample was diverse; 42.6% were white, 25.5% Latino, 23.1% black, and 8.8% of other ethnic background. Primary diagnosis included cancer (33.8%), congestive heart failure (CHF) (17.4%), coronary artery disease (12.6%), dementia (12.4%), chronic obstructive pulmonary disease (6%), cerebral vascular accident (CVA) (5.2%), and other conditions (13.6%). More than half (57.7%) were discharged to hospice, 15.4% to home‐based palliative care,[6] 14.6% to a nursing facility, 8.2% to home with usual outpatient care, and 4.1% to home with home healthcare. Code status was discussed by the IPC team among 81% of the patients, with no difference between ethnic groups.
Those discharged to hospice were older (80.8, SD=8.4 vs 79.1, SD=7.8), more likely to have cancer (71.5%) or CVA (79.5%) and less likely to have end stage renal disease (28.6%) or CHF (39%), and more likely to have had a code discussion (85.8%). There were no differences between hospice users and nonusers in gender, marital status, ethnicity, and number of chronic conditions (Table 1).
| Variable | All, N=364 | Hospice Users, n=210 | Nonhospice Users, n=154 | P Value |
|---|---|---|---|---|
| ||||
| Age, y, mean (SD) | 80.1 (8.2) | 80.8 (8.4) | 79.1 (7.8) | 0.049 |
| Gender (female), % | 48.9 | 56.2 | 43.8 | 0.568 |
| Ethnicity, % | 0.702 | |||
| White | 42.6 | 43.3 | 41.6 | |
| Latino | 25.5 | 27.1 | 23.4 | |
| African American | 23.1 | 21.4 | 25.3 | |
| Other | 8.8 | 8.1 | 9.7 | |
| Marital status, % | 0.809 | |||
| Married | 45.6 | 43.8 | 48.1 | |
| Widowed | 36.0 | 38.1 | 33.1 | |
| Divorced | 7.7 | 7.6 | 7.8 | |
| Other | 7.7 | 7.6 | 7.8 | |
| Missing | 3.0 | 2.9 | 3.2 | |
| Diagnosis, % | <0.001 | |||
| Cancer | 33.8 | 42.1 | 22.9 | |
| CHF | 16.2 | 11.0 | 23.5 | |
| CAD | 12.6 | 12.4 | 13.1 | |
| Dementia | 12.4 | 12.4 | 12.4 | |
| COPD | 6.0 | 5.3 | 7.2 | |
| CVA | 5.2 | 7.2 | 2.6 | |
| Other | 13.6 | 9.6 | 18.3 | |
| Number of chronic conditions, mean (SD) | 1.0 | 1.7 (0.8) | 1.7 (0.9) | 0.949 |
| Code status discussed, % | 81.1 | 87.0 | 72.8 | 0.001 |
Significant differences between hospice users and nonusers were controlled in a regression adjusting for age, gender, marital status, and number of chronic conditions. Compared to whites, no significant differences in hospice use were found for blacks (odds ratio [OR]: 0.67; 95% confidence interval [CI]: 0.37‐1.21), Latinos (OR: 1.24; 95% CI: 0.68‐2.25), or other ethnic groups (OR: 0.78; 95% CI: 0.34‐1.56). Compared with other diagnoses, those with cancer (OR: 3.66; 95% CI: 1.77‐7.59) and older patients (OR: 1.05; 95% CI: 1.01‐1.08) were significantly more likely to receive hospice care following IPC consult. Those discussing code status were twice as likely to be discharged to hospice (OR: 2.14; 95% CI: 1.20‐3.79).
DISCUSSION
This study found similar rates of hospice enrollment following IPC consult among Latinos, blacks, and other ethnic groups as compared with whites. Others found comparable rates of advance directive completion between whites and African Americans following IPC consultation,[7]and that IPC intensity resulting in a plan of care was highly associated with receipt of hospice care.[8] Likewise, our study found that discussion of code status, another marker of intensity, was positively associated with hospice use.
Our findings among patients receiving IPC consultation contrast with previous studies examining ethnic variation in hospice use among general samples of decedents. A study of California dual eligibles found that blacks were 26% and Asians 34% less likely than whites to use hospice. Others have found similar results among patients with CHF and lung cancer.[9, 10]
Misconceptions and lack of awareness, knowledge, and trust in healthcare providers serve as barriers to hospice care for minorities.[11, 12] IPC consultations may overcome these barriers by discussing goals of care including discussing the condition, eliciting patient/family understanding of the condition, and presenting options for code status.
This study employed a single‐cohort design without a comparison group. It was conducted within a health maintenance organization with strong hospice and palliative care programs and may not represent other settings. Nevertheless, this study provides promise for IPC consultation to increase equitable access to hospice care among minority groups. Further studies are needed to confirm the preliminary findings reported here.
Disclosures: Supported in part by a career development award from the National Palliative Care Research Center and by a grant from the Archstone Foundation. Evie Vesper and Dr. Rebecca Goldstein were employees of the healthcare organization at the time of the study. Susan Enguidanos received compensation for project evaluation during the original study. The sponsors had no role in the design, implementation, or analysis of the study. The authors report no conflicts of interest.
- , , . Ethnic variation in site of death among Medicaid/Medicare dually eligible older adults. J Am Geriatr Soc. 2005;53(8):1411–1416.
- . Racial/ethnic disparities in hospice care: a systematic review. J Palliat Med. 2008;11(5):763–768.
- . The Medicare hospice benefit: 15 years of success. J Palliat Med. 1998;1(2):139–146.
- . Palliative care in hospitals. J Hosp Med. 2006;1(1):21–28.
- , , , et al. Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med. 2008;11(2):180–190.
- , , , et al. Increased satisfaction with care and lower costs: results of a randomized trial of in‐home palliative care. J Am Geriatr Soc. 2007;55(7):993–1000.
- , , , et al. Ethnicity, race, and advance directives in an inpatient palliative care consultation service. Palliat Support Care. 2012;6(1):1–7.
- , , . Hospice referrals and code status: outcomes of inpatient palliative care consultations among Asian Americans and Pacific Islanders with cancer. J Pain Symptom Manage. 2011;42(4):557–564.
- , , , , . Racial differences in hospice use and patterns of care after enrollment in hospice among Medicare beneficiaries with heart failure. Am Heart J. 2012;163(6):987–993.
- , , , et al. Racial disparities in length of stay in hospice care by tumor stage in a large elderly cohort with non‐small cell lung cancer. Palliat Med. 2012;26(1):61–71.
- , , , , . Knowledge, attitudes and beliefs about end‐of‐life care among inner‐city African Americans and Latino/Hispanic Americans. J Palliat Med. 2004;7(2):247–256.
- , , . Does caregiver knowledge matter for hospice enrollment and beyond? Pilot study of minority hospice patients. Am J Hospice Palliat Med. 2009;26(3):165–171.
Studies have documented the persisting lower rates of hospice enrollment among ethnic minority groups.[1, 2] Given the positive outcomes related to hospice enrollment,[3] investigating interventions that may reduce these disparities is critical.
Inpatient palliative care (IPC) programs were developed to improve pain and symptom management, provide patients with holistic and comprehensive prognosis and treatment options, and help patient and families clarify goals of care.[4] Although significant evidence of IPC program effectiveness in improving patient outcomes exists,[5] studies have not examined the ability of IPC programs to diminish ethnic disparities in access to hospice. We conducted a retrospective cohort study to determine if ethnic differences in hospice enrollment are experienced among patients following receipt of IPC consultation.
METHODS
A retrospective study was conducted in a nonprofit health maintenance organization medical center. The sample included seriously ill patients aged 65 years and over who received an IPC consultation and survived to hospital discharge. Data were collected from IPC databases, IPC consultation checklist (which included recording of code status discussion), and electronic medical records. The IPC team recorded discharge disposition including discharge to hospice care, home‐based palliative care (a standard program similar to hospice but offered for patients with an estimated prognosis of 1 year or less and without the caveat of foregoing curative care),[6] home with home healthcare, nursing facility, and home with standard outpatient care. Ethnicity was collected via patient report.
2 and t tests were conducted to compare those admitted to hospice with those who were not. We used logistic regression to determine the effects of ethnicity on enrollment in hospice, adjusting for demographics and clinical factors. We conducted analysis using IBM SPSS 19 (IBM, Armonk, NY).
FINDINGS
From 2007 to 2009, 408 patients received IPC consults and were subsequently discharged from the hospital. Forty‐four had missing data on ethnicity or discharge disposition, leaving 364 in the analytic sample. The mean age was 80.1 years (standard deviation [SD]=8.2), and 48.9% were female. The sample was diverse; 42.6% were white, 25.5% Latino, 23.1% black, and 8.8% of other ethnic background. Primary diagnosis included cancer (33.8%), congestive heart failure (CHF) (17.4%), coronary artery disease (12.6%), dementia (12.4%), chronic obstructive pulmonary disease (6%), cerebral vascular accident (CVA) (5.2%), and other conditions (13.6%). More than half (57.7%) were discharged to hospice, 15.4% to home‐based palliative care,[6] 14.6% to a nursing facility, 8.2% to home with usual outpatient care, and 4.1% to home with home healthcare. Code status was discussed by the IPC team among 81% of the patients, with no difference between ethnic groups.
Those discharged to hospice were older (80.8, SD=8.4 vs 79.1, SD=7.8), more likely to have cancer (71.5%) or CVA (79.5%) and less likely to have end stage renal disease (28.6%) or CHF (39%), and more likely to have had a code discussion (85.8%). There were no differences between hospice users and nonusers in gender, marital status, ethnicity, and number of chronic conditions (Table 1).
| Variable | All, N=364 | Hospice Users, n=210 | Nonhospice Users, n=154 | P Value |
|---|---|---|---|---|
| ||||
| Age, y, mean (SD) | 80.1 (8.2) | 80.8 (8.4) | 79.1 (7.8) | 0.049 |
| Gender (female), % | 48.9 | 56.2 | 43.8 | 0.568 |
| Ethnicity, % | 0.702 | |||
| White | 42.6 | 43.3 | 41.6 | |
| Latino | 25.5 | 27.1 | 23.4 | |
| African American | 23.1 | 21.4 | 25.3 | |
| Other | 8.8 | 8.1 | 9.7 | |
| Marital status, % | 0.809 | |||
| Married | 45.6 | 43.8 | 48.1 | |
| Widowed | 36.0 | 38.1 | 33.1 | |
| Divorced | 7.7 | 7.6 | 7.8 | |
| Other | 7.7 | 7.6 | 7.8 | |
| Missing | 3.0 | 2.9 | 3.2 | |
| Diagnosis, % | <0.001 | |||
| Cancer | 33.8 | 42.1 | 22.9 | |
| CHF | 16.2 | 11.0 | 23.5 | |
| CAD | 12.6 | 12.4 | 13.1 | |
| Dementia | 12.4 | 12.4 | 12.4 | |
| COPD | 6.0 | 5.3 | 7.2 | |
| CVA | 5.2 | 7.2 | 2.6 | |
| Other | 13.6 | 9.6 | 18.3 | |
| Number of chronic conditions, mean (SD) | 1.0 | 1.7 (0.8) | 1.7 (0.9) | 0.949 |
| Code status discussed, % | 81.1 | 87.0 | 72.8 | 0.001 |
Significant differences between hospice users and nonusers were controlled in a regression adjusting for age, gender, marital status, and number of chronic conditions. Compared to whites, no significant differences in hospice use were found for blacks (odds ratio [OR]: 0.67; 95% confidence interval [CI]: 0.37‐1.21), Latinos (OR: 1.24; 95% CI: 0.68‐2.25), or other ethnic groups (OR: 0.78; 95% CI: 0.34‐1.56). Compared with other diagnoses, those with cancer (OR: 3.66; 95% CI: 1.77‐7.59) and older patients (OR: 1.05; 95% CI: 1.01‐1.08) were significantly more likely to receive hospice care following IPC consult. Those discussing code status were twice as likely to be discharged to hospice (OR: 2.14; 95% CI: 1.20‐3.79).
DISCUSSION
This study found similar rates of hospice enrollment following IPC consult among Latinos, blacks, and other ethnic groups as compared with whites. Others found comparable rates of advance directive completion between whites and African Americans following IPC consultation,[7]and that IPC intensity resulting in a plan of care was highly associated with receipt of hospice care.[8] Likewise, our study found that discussion of code status, another marker of intensity, was positively associated with hospice use.
Our findings among patients receiving IPC consultation contrast with previous studies examining ethnic variation in hospice use among general samples of decedents. A study of California dual eligibles found that blacks were 26% and Asians 34% less likely than whites to use hospice. Others have found similar results among patients with CHF and lung cancer.[9, 10]
Misconceptions and lack of awareness, knowledge, and trust in healthcare providers serve as barriers to hospice care for minorities.[11, 12] IPC consultations may overcome these barriers by discussing goals of care including discussing the condition, eliciting patient/family understanding of the condition, and presenting options for code status.
This study employed a single‐cohort design without a comparison group. It was conducted within a health maintenance organization with strong hospice and palliative care programs and may not represent other settings. Nevertheless, this study provides promise for IPC consultation to increase equitable access to hospice care among minority groups. Further studies are needed to confirm the preliminary findings reported here.
Disclosures: Supported in part by a career development award from the National Palliative Care Research Center and by a grant from the Archstone Foundation. Evie Vesper and Dr. Rebecca Goldstein were employees of the healthcare organization at the time of the study. Susan Enguidanos received compensation for project evaluation during the original study. The sponsors had no role in the design, implementation, or analysis of the study. The authors report no conflicts of interest.
Studies have documented the persisting lower rates of hospice enrollment among ethnic minority groups.[1, 2] Given the positive outcomes related to hospice enrollment,[3] investigating interventions that may reduce these disparities is critical.
Inpatient palliative care (IPC) programs were developed to improve pain and symptom management, provide patients with holistic and comprehensive prognosis and treatment options, and help patient and families clarify goals of care.[4] Although significant evidence of IPC program effectiveness in improving patient outcomes exists,[5] studies have not examined the ability of IPC programs to diminish ethnic disparities in access to hospice. We conducted a retrospective cohort study to determine if ethnic differences in hospice enrollment are experienced among patients following receipt of IPC consultation.
METHODS
A retrospective study was conducted in a nonprofit health maintenance organization medical center. The sample included seriously ill patients aged 65 years and over who received an IPC consultation and survived to hospital discharge. Data were collected from IPC databases, IPC consultation checklist (which included recording of code status discussion), and electronic medical records. The IPC team recorded discharge disposition including discharge to hospice care, home‐based palliative care (a standard program similar to hospice but offered for patients with an estimated prognosis of 1 year or less and without the caveat of foregoing curative care),[6] home with home healthcare, nursing facility, and home with standard outpatient care. Ethnicity was collected via patient report.
2 and t tests were conducted to compare those admitted to hospice with those who were not. We used logistic regression to determine the effects of ethnicity on enrollment in hospice, adjusting for demographics and clinical factors. We conducted analysis using IBM SPSS 19 (IBM, Armonk, NY).
FINDINGS
From 2007 to 2009, 408 patients received IPC consults and were subsequently discharged from the hospital. Forty‐four had missing data on ethnicity or discharge disposition, leaving 364 in the analytic sample. The mean age was 80.1 years (standard deviation [SD]=8.2), and 48.9% were female. The sample was diverse; 42.6% were white, 25.5% Latino, 23.1% black, and 8.8% of other ethnic background. Primary diagnosis included cancer (33.8%), congestive heart failure (CHF) (17.4%), coronary artery disease (12.6%), dementia (12.4%), chronic obstructive pulmonary disease (6%), cerebral vascular accident (CVA) (5.2%), and other conditions (13.6%). More than half (57.7%) were discharged to hospice, 15.4% to home‐based palliative care,[6] 14.6% to a nursing facility, 8.2% to home with usual outpatient care, and 4.1% to home with home healthcare. Code status was discussed by the IPC team among 81% of the patients, with no difference between ethnic groups.
Those discharged to hospice were older (80.8, SD=8.4 vs 79.1, SD=7.8), more likely to have cancer (71.5%) or CVA (79.5%) and less likely to have end stage renal disease (28.6%) or CHF (39%), and more likely to have had a code discussion (85.8%). There were no differences between hospice users and nonusers in gender, marital status, ethnicity, and number of chronic conditions (Table 1).
| Variable | All, N=364 | Hospice Users, n=210 | Nonhospice Users, n=154 | P Value |
|---|---|---|---|---|
| ||||
| Age, y, mean (SD) | 80.1 (8.2) | 80.8 (8.4) | 79.1 (7.8) | 0.049 |
| Gender (female), % | 48.9 | 56.2 | 43.8 | 0.568 |
| Ethnicity, % | 0.702 | |||
| White | 42.6 | 43.3 | 41.6 | |
| Latino | 25.5 | 27.1 | 23.4 | |
| African American | 23.1 | 21.4 | 25.3 | |
| Other | 8.8 | 8.1 | 9.7 | |
| Marital status, % | 0.809 | |||
| Married | 45.6 | 43.8 | 48.1 | |
| Widowed | 36.0 | 38.1 | 33.1 | |
| Divorced | 7.7 | 7.6 | 7.8 | |
| Other | 7.7 | 7.6 | 7.8 | |
| Missing | 3.0 | 2.9 | 3.2 | |
| Diagnosis, % | <0.001 | |||
| Cancer | 33.8 | 42.1 | 22.9 | |
| CHF | 16.2 | 11.0 | 23.5 | |
| CAD | 12.6 | 12.4 | 13.1 | |
| Dementia | 12.4 | 12.4 | 12.4 | |
| COPD | 6.0 | 5.3 | 7.2 | |
| CVA | 5.2 | 7.2 | 2.6 | |
| Other | 13.6 | 9.6 | 18.3 | |
| Number of chronic conditions, mean (SD) | 1.0 | 1.7 (0.8) | 1.7 (0.9) | 0.949 |
| Code status discussed, % | 81.1 | 87.0 | 72.8 | 0.001 |
Significant differences between hospice users and nonusers were controlled in a regression adjusting for age, gender, marital status, and number of chronic conditions. Compared to whites, no significant differences in hospice use were found for blacks (odds ratio [OR]: 0.67; 95% confidence interval [CI]: 0.37‐1.21), Latinos (OR: 1.24; 95% CI: 0.68‐2.25), or other ethnic groups (OR: 0.78; 95% CI: 0.34‐1.56). Compared with other diagnoses, those with cancer (OR: 3.66; 95% CI: 1.77‐7.59) and older patients (OR: 1.05; 95% CI: 1.01‐1.08) were significantly more likely to receive hospice care following IPC consult. Those discussing code status were twice as likely to be discharged to hospice (OR: 2.14; 95% CI: 1.20‐3.79).
DISCUSSION
This study found similar rates of hospice enrollment following IPC consult among Latinos, blacks, and other ethnic groups as compared with whites. Others found comparable rates of advance directive completion between whites and African Americans following IPC consultation,[7]and that IPC intensity resulting in a plan of care was highly associated with receipt of hospice care.[8] Likewise, our study found that discussion of code status, another marker of intensity, was positively associated with hospice use.
Our findings among patients receiving IPC consultation contrast with previous studies examining ethnic variation in hospice use among general samples of decedents. A study of California dual eligibles found that blacks were 26% and Asians 34% less likely than whites to use hospice. Others have found similar results among patients with CHF and lung cancer.[9, 10]
Misconceptions and lack of awareness, knowledge, and trust in healthcare providers serve as barriers to hospice care for minorities.[11, 12] IPC consultations may overcome these barriers by discussing goals of care including discussing the condition, eliciting patient/family understanding of the condition, and presenting options for code status.
This study employed a single‐cohort design without a comparison group. It was conducted within a health maintenance organization with strong hospice and palliative care programs and may not represent other settings. Nevertheless, this study provides promise for IPC consultation to increase equitable access to hospice care among minority groups. Further studies are needed to confirm the preliminary findings reported here.
Disclosures: Supported in part by a career development award from the National Palliative Care Research Center and by a grant from the Archstone Foundation. Evie Vesper and Dr. Rebecca Goldstein were employees of the healthcare organization at the time of the study. Susan Enguidanos received compensation for project evaluation during the original study. The sponsors had no role in the design, implementation, or analysis of the study. The authors report no conflicts of interest.
- , , . Ethnic variation in site of death among Medicaid/Medicare dually eligible older adults. J Am Geriatr Soc. 2005;53(8):1411–1416.
- . Racial/ethnic disparities in hospice care: a systematic review. J Palliat Med. 2008;11(5):763–768.
- . The Medicare hospice benefit: 15 years of success. J Palliat Med. 1998;1(2):139–146.
- . Palliative care in hospitals. J Hosp Med. 2006;1(1):21–28.
- , , , et al. Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med. 2008;11(2):180–190.
- , , , et al. Increased satisfaction with care and lower costs: results of a randomized trial of in‐home palliative care. J Am Geriatr Soc. 2007;55(7):993–1000.
- , , , et al. Ethnicity, race, and advance directives in an inpatient palliative care consultation service. Palliat Support Care. 2012;6(1):1–7.
- , , . Hospice referrals and code status: outcomes of inpatient palliative care consultations among Asian Americans and Pacific Islanders with cancer. J Pain Symptom Manage. 2011;42(4):557–564.
- , , , , . Racial differences in hospice use and patterns of care after enrollment in hospice among Medicare beneficiaries with heart failure. Am Heart J. 2012;163(6):987–993.
- , , , et al. Racial disparities in length of stay in hospice care by tumor stage in a large elderly cohort with non‐small cell lung cancer. Palliat Med. 2012;26(1):61–71.
- , , , , . Knowledge, attitudes and beliefs about end‐of‐life care among inner‐city African Americans and Latino/Hispanic Americans. J Palliat Med. 2004;7(2):247–256.
- , , . Does caregiver knowledge matter for hospice enrollment and beyond? Pilot study of minority hospice patients. Am J Hospice Palliat Med. 2009;26(3):165–171.
- , , . Ethnic variation in site of death among Medicaid/Medicare dually eligible older adults. J Am Geriatr Soc. 2005;53(8):1411–1416.
- . Racial/ethnic disparities in hospice care: a systematic review. J Palliat Med. 2008;11(5):763–768.
- . The Medicare hospice benefit: 15 years of success. J Palliat Med. 1998;1(2):139–146.
- . Palliative care in hospitals. J Hosp Med. 2006;1(1):21–28.
- , , , et al. Impact of an inpatient palliative care team: a randomized control trial. J Palliat Med. 2008;11(2):180–190.
- , , , et al. Increased satisfaction with care and lower costs: results of a randomized trial of in‐home palliative care. J Am Geriatr Soc. 2007;55(7):993–1000.
- , , , et al. Ethnicity, race, and advance directives in an inpatient palliative care consultation service. Palliat Support Care. 2012;6(1):1–7.
- , , . Hospice referrals and code status: outcomes of inpatient palliative care consultations among Asian Americans and Pacific Islanders with cancer. J Pain Symptom Manage. 2011;42(4):557–564.
- , , , , . Racial differences in hospice use and patterns of care after enrollment in hospice among Medicare beneficiaries with heart failure. Am Heart J. 2012;163(6):987–993.
- , , , et al. Racial disparities in length of stay in hospice care by tumor stage in a large elderly cohort with non‐small cell lung cancer. Palliat Med. 2012;26(1):61–71.
- , , , , . Knowledge, attitudes and beliefs about end‐of‐life care among inner‐city African Americans and Latino/Hispanic Americans. J Palliat Med. 2004;7(2):247–256.
- , , . Does caregiver knowledge matter for hospice enrollment and beyond? Pilot study of minority hospice patients. Am J Hospice Palliat Med. 2009;26(3):165–171.