Close but unreachable: racial disparities in hospice utilization beyond geographic proximity among older adult patients with cancer

Hospice care reduces the use of aggressive care at the end-of-life; however, not everyone receives this supportive care. This study examines patterns in the relationship between hospice availability and hospice care utilization among Medicare fee-for-service beneficiaries with poor-prognosis cancer in the United States during 2018. We analyzed this association while accounting for age, sex, race/ethnicity, driving distance to hospice, rurality, neighborhood income, and neighborhood racial composition using a logistic mixed-effect regression model. We also stratified analyses by race/ethnic sub-groups and distance ranges from a hospice. We found that beneficiaries who were female, older, and lived in urban ZIP codes had higher odds of hospice enrollment than their counterparts. In contrast, Black, Hispanic, or Asian beneficiaries had lower odds of hospice use than White beneficiaries. Contextual factors, including neighborhood income and racial composition, showed statistically significant interactions with beneficiary race, indicating heterogeneous effects across groups. In contrast, proximity to hospice did not demonstrate meaningful effect modification across other predictors in stratified analyses. These findings suggest that geographic proximity alone does not fully explain patterns of hospice utilization. Rather, hospice use is shaped by interacting structural and sociodemographic factors that vary across populations. Our results highlight the need for a pathway-based model grounded in systems thinking that captures how, when, and through what interactions multiple factors emerge and influence hospice decision-making over time. Such an approach may provide clearer intervention targets and better explain persistent disparities in hospice utilization among Black, Hispanic, and Asian patients at the end-of-life. Female, older, and urban beneficiaries had higher odds of enrolling in hospice. Black, Hispanic, and Asian patients had lower odds of hospice use than White beneficiaries. Geographic proximity to hospice alone is an insufficient measure of hospice access. A systems thinking approach can help identify gaps and structural barriers in decision-making for hospice enrollment.