Association of Hospice Patients' Income and Care Level With Place of Death

Importance: Terminally ill patients with lower incomes are less likely to die at home, even with hospice care. Objectives: To examine the relationship between income and transfer from home before death and the interaction between income and level of hospice care as a predictor of transfer from home in patients admitted to routine home hospice care. Design: We matched zip codes to US census tracts to generate median annual household incomes and divided the measure into $10 000 increments (<=$20 000 to >$50 000). We abstracted data from the central administrative and clinical database of a hospice care provider. We analyzed the relationship between income and transfer from home before death using logistic regression adjusted for demographics, diagnosis, region, and length of stay. Level of hospice care was examined as any continuous care vs none. Unlike routine care, which includes periodic visits by hospice, continuous care is a higher level of care used for short periods of crisis to keep a patient at home and includes hospice services in the home at least 8 hours in a 24-hour period. Setting: A for-profit hospice provider, VITAS Healthcare, operating 26 programs in 8 states. Participants: Hospice patients admitted to routine care in a private residence from January 1, 1999, through December 31, 2003. Main Outcome Measure: Transfer from hospice care in a private residence to hospice care in a site outside the home before death. Results: Of the 61 063 enrollees admitted to routine care in a private residence, 13 804 (22.61%) transferred from home to another location (ie, inpatient hospice unit or nursing home) with hospice care before death. Patients who transferred had a lower mean median household income ($42 585 vs $46 777; P<.001) and were less likely to have received any continuous care (49.38% vs 30.61%; P<.001). The median number of days of continuous care was 4. For patients who did not receive continuous care, the odds of transfer from home before death increased with decreasing median annual household incomes (odds ratio range, 1.26-1.76). For patients who received continuous care, income was not a predictor of transfer from home. Conclusions and Relevance: Patients with limited resources may be less likely to die at home, especially if they are not able to access needed support beyond what is available with routine hospice care.