Trends in Hospice Use among Older Adults with Dementia and Cancer by Race and Ethnicity, 2011–2021

Key Message : In this national Medicare study (2011–2021), hospice use increased across racial and ethnic groups for both dementia and cancer, yet disparities remained flat or widened for Black, Hispanic, and AI/AN decedents. Parallel trends across diagnoses highlight the need for interventions addressing systemic and social drivers of inequity, beyond disease-specific efforts.

Abstract:

Background:
Hospice enrollment among older adults has grown substantially, yet racial and ethnic disparities persist. Whether these disparities have narrowed over time or differ by condition remains unclear. Understanding trends by diagnosis and race/ethnicity may inform equitable expansion of hospice access.

Objectives:
To examine national trends in hospice use among Medicare decedents with dementia and cancer (2011–2021) and assess whether racial and ethnic disparities changed over time.

Methods:
We used 100% Medicare claims to identify fee-for-service beneficiaries aged ≥66 who died from 2011–2021 with dementia (Bynum algorithm) or cancer (validated ICD-9/10 codes). Race/ethnicity was classified via the Research Triangle Institute algorithm. Hospice use was defined as ≥1 day of enrollment within 365 days of death. Linear probability models estimated annual change in hospice use, including three-way interactions between year, diagnosis, and race/ethnicity, adjusted for age and sex. Sensitivity analyses used logistic regression and pre-COVID restriction (≤2019).

Results:
Among 7.2 million decedents (2.3M cancer, 4.9M dementia), hospice use increased for both groups (cancer: 68.5%→71.8%; dementia: 54.9%→64.9%). Growth was faster for dementia (+10.8 percentage points/decade) than cancer (+3.9). Disparities remained flat or widened for Black, Hispanic, and AI/AN decedents, while narrowing modestly for AAPI decedents. For dementia, hospice use rose by 11.3 percentage points among White decedents versus 8.2 (Black), 9.1 (Hispanic), and 7.9 (AI/AN). Similar patterns were observed in cancer.

Conclusions:
From 2011–2021, hospice use increased across racial and ethnic groups for dementia and cancer, but longstanding disparities persisted or widened. Parallel trends across diagnoses suggest that addressing systemic and social drivers is essential to advance equity in hospice access.

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