Use of hospice care, which provides dying patients with relief of pain and other symptoms either at home or in a hospice center, varied more than 11-fold across U.S. metropolitan statistical areas in 1996. This variation was not explained by differences in the major components of the health care infrastructure—such as the availability of hospital, nursing home, or skilled nursing facilities—or by the availability of HMOs, doctors, or generalists. Rather, the difference seems to be due to important local factors such as local preferences, differences in the particular mix of services provided by local hospices, or even differences in community leadership on end-of-life issues, according to a recent study that was supported in part by the Agency for Healthcare Research and Quality (National Research Service Award training grant T32 HS00084).
Virginia W. Chang, M.D., M.A., of the University of Chicago, and her colleagues examined Medicare claims data for a group of elderly patients newly diagnosed with lung cancer, colon cancer, stroke, or heart attack in 1993, and followed them for up to 5 years. They linked data on use of hospice care by those who died to Census and Area Resource File data on county-level variables (for example, number of hospital beds) to determine the power of market-level structure and local demographics to explain variation between 1,530 counties in rates of hospice use.
Local demographics explained 2.5 percent and market factors explained 0.7 percent of the between-county variation. Three demographic factors were significant. Individuals living in counties with more white collar employees, people living in the least densely populated counties, and those living in counties with relatively more cancer deaths were more likely to use hospice care. None of the county-level health care market factors were significantly associated with differences in use of hospice care.
More details are in "The lack of effect of market structure on hospice use," by Theodore J. Iwashyna, M.D., Ph.D., Dr. Chang, James X. Zhang, Ph.D., M.S., and Nicholas A. Christakis, M.D., Ph.D., M.P.H., in the December 2002 Health Services Research 37(6), pp. 1531-1551.