• David G Stevenson, Haiden A Huskamp, David C Grabowski, and Nancy L Keating.
• Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts 02115, USA. stevenson@hcp.med.harvard.edu
• J Palliat Med. 2007 Oct 1;10(5):1040-7.

ObjectiveTo compare hospice care delivered at home with hospice care delivered in institutional settings, such as the nursing home.Data SourceSecondary data from the 1994, 1996, 1998, and 2000 waves of the National Home and Hospice Care Survey, a nationally representative survey of home health and hospice care agencies in the United States and their current and discharged patients.Study DesignWe describe recipients, use of services, and length of enrollment for hospice received at home compared to hospice received in institutional settings. Comparisons of service use and lengths of enrollment are adjusted for age, gender, race/ethnicity, location, Charlson score, payer status, and linear time trends.Principal FindingsHospice use in the United States has grown considerably over the last decade, especially among individuals in institutional settings. Institutional hospice users were older than home hospice users; more likely to be female, unmarried, and dually eligible for Medicare and Medicaid; and more likely to have primary diagnoses other than cancer. Although institutional hospice users were more likely to have received certain types of services compared to recipients at home, they were much more likely to be enrolled for 1 week or less.ConclusionsThese national data point to significant differences across hospice settings and a growing need to analyze their implications. Yet, these data also leave many questions about hospice use across settings unanswered, including whether agency costs differ in institutional compared to home settings. As policymakers seek to assess the quality and appropriateness of hospice utilization and the methods used for its payment, further empirical work is needed, including how the growing use of hospice outside the home affects options for reform.

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