Our study can be summarized as follows. Hispanics and non-Hispanic whites with a diagnosis of cancer were found to use hospice services at similar rates. A significant difference in hospice use between Hispanics and non-Hispanic whites was detected in an unadjusted model, but the difference disappeared in adjusted models controlling for sociodemographic characteristics, type of insurance, type of cancer, and SEER area. Ethnicity, age at death, and having a diagnosis of colorectal cancer were the only variables not associated with hospice use. This finding is noteworthy because of the large sample size. Significant associations can often be detected when samples are overpowered for statistical analyses. Therefore, associations that are not significant with large samples are particularly striking.
Separate analyses for each cancer site demonstrate that it is only among women with breast cancer that Hispanics are significantly less likely to use hospice services in comparison to non-Hispanic whites. Another noteworthy finding for women dying of breast cancer is that hospice enrollment was equally likely to occur in married and unmarried subjects. Finally, two significant interactions with ethnicity were observed, ethnicity by type of insurance and ethnicity by SEER site. After adjusting for sociodemographic characteristics, type of insurance, type of cancer, and SEER area, Hispanic subjects were less likely to use hospice if enrolled in fee-for-service Medicare. Hispanic subjects were also significantly less likely to use hospice than non-Hispanic whites if residing in Los Angeles.
There are limited studies that have reported on proportions of hospice use among Hispanics (Lackan, Freeman, and Goodwin 2003
; Pawling-Kaplan and O'Connor 1989
; McCuistion 1994
; National Hospice and Palliative Care Organization 2002
). Three of these studies reported that Hispanics used hospice services less than non-Hispanic whites. However, they were either limited to single hospice sites or lacked denominator data, thus making comparisons in rates of use across ethnic groups difficult. In a previous study, we found no difference in hospice among non-Hispanic whites, African Americans, Hispanics, and Asian/Pacific Islanders. That study only examined older women diagnosed with breast cancer. The present study is the first to compare rates of hospice use between Hispanics and non-Hispanic whites using a population-based sample of men and women diagnosed with one of the four leading cancers.
While the National Hospice and Palliative Care Organization study did not include denominator data, its findings are still striking. Briefly, the study reported that in 2000, 82 percent of hospice patients were non-Hispanic white and 3.4 percent were Hispanic. According to year 2000 data from the U.S. Census Bureau, non-Hispanic whites comprised 70.6 percent of the population and Hispanics comprised 12 percent in that year (Therrien and Ramirez 2000
). The 3.4 percent hospice use among Hispanics reported by the National Hospice and Palliative Care Organization is much lower than what we found and also much lower than the proportion of Hispanics in the nation. It is possible that this study found lower hospice use among Hispanics because it included all hospice patients, not just older adults. On average, Hispanics are younger than non-Hispanic whites (Therrien and Ramirez 2000
) and hospice services are primarily used by older adults (Cassel and Field 1997
). Another explanation might be that information on patient ethnicity may be more accurate in the SEER data.
Given the eligibility requirements of the Medicare Hospice Benefit and the strong social support networks of Hispanic cultures, our finding that Hispanics and non-Hispanic whites use hospice at similar rates makes sense. The Medicare Hospice Benefit requires that hospice patients have a caregiver available for at least 19 hours per day. This requirement, known as the “caregiver rule,” prohibits many older adults from enrolling in hospice care. Older adults who live alone, who do not have close friends or relatives able to commit to providing nearly full-time care, or who may not be able to afford custodial care are ineligible for hospice services under the Medicare Hospice Benefit because of the “caregiver rule” (Gordon 1995
It is doubtful that the “caregiver rule” is a prohibitive factor in traditional Hispanic communities. Hispanic cultures have strong kinship networks and the strength of these support networks is well-documented (Aranda and Knight 1997
; Aranda and Miranda 1997
). Hispanic households are often comprised of extended families and multiple generations, thus increasing the potential availability of hospice caregivers.
Another characteristic of Hispanic cultures that facilitates the use of hospice care is the cultural attitude toward caregiving. Cultural norms dictate that family members should be cared for in the home by their loved ones for as long as possible (Angel et al. 1996
; Markides et al. 1997
). This is evidenced by the lower use of institutional care (e.g., nursing homes) by Hispanics (Dey 1997
; Angel and Angel 1997
). This preference for caring for family members at home versus institutional settings is consistent with the ideals of hospice care.
Our study is limited in that only subjects who died with breast, colorectal, lung, and prostate cancer were included in the study. While these are the most frequently occurring cancers for adults age 65 and over (Edwards et al. 2002
), the use of hospice among patients with noncancer diagnoses is increasing (National Hospice and Palliative Care Organization 2002
). It is important that ethnic differences among patients with noncancer diagnoses are also investigated. In addition, while the SEER-Medicare data are an excellent source to study older patients diagnosed with cancer who subsequently use hospice, they are limited in their generalizability to older adults across the country. The SEER-Medicare population is more racially and ethnically diverse, has a greater percentage of urban residents, is more highly educated, and has a higher income than the older adult population of the United States (Warren et al. 2002
; Nattinger et al. 1997
). There remains debate surrounding the accuracy of reporting of Hispanic ethnicity in the SEER data. A study by Swallen et al. (1997)
examining misclassification of Hispanics in the San Francisco SEER registry identified both overreporting and underreporting of Hispanics. Misclassification of individuals of Hispanic ethnicity differed for males and females and was found to be associated with acculturation and sociodemographic characteristics such as age and education. Since our study demonstrates that hospice use between Hispanics and non-Hispanic whites is similar, it is unlikely that underreporting of Hispanics will bias our results. Swallen and colleagues suggested that in cases of overreporting, Hispanic ethnicity was confused with membership in another nonwhite ethnic group. If this is the case, it is not likely that this type of overreporting would bias our results. Another limitation is the lack of detailed information about populations within the Hispanic ethnic group. The term “Hispanic” is used to describe several groups including Mexican Americans, Cubans, and Puerto Ricans. Further research is necessary to investigate hospice use within these groups since it has been demonstrated that these groups differ with respect to the use of other health services, such as number of physician visits per year (Burnette and Mui 1999
; Trevino and Moss 1984
Our findings suggest that while some minority groups may use hospice services less than non-Hispanic whites, it cannot be assumed that all minority groups do so. Further research is necessary to examine hospice use in other minority groups.