More patients suffering from cardiovascular disease are dying in their homes rather than in the hospital, a new study has found. However, racial and socioeconomic disparities continue to have an impact on where patients end their lives.

Between 2003 and 2017 nearly 31% of patients suffering from conditions such as heart failure, ischemic heart disease, stroke or cardiomyopathy died in their homes, up from 21.3%. Whereas the number who passed away in a hospital dropped to 27.3% from 36%. Significant drops in the number of these patients who died in a nursing facilities also occurred.

“Home has become the most common place of death for [cardiovascular disease] patients, reinforcing the need for more information about the experiences of these patients. Even if home is the preferred location of death for many patients, concerns remain regarding potential limited access to resources and caregivers during acute exacerbations,” the researchers concluded in the study. “Care preferences and experiences of minority patients and caregivers deserve further attention. Demographic and disease-related factors should be considered in designing patient-centered interventions to improve end-of-life care.”

A team of researchers analyzed National Center for Health Statistics data as well as data from the U.S. Centers for Disease Control and Prevention regarding 12.3 million natural deaths that occurred between 2003 and 2017 that were associated with cardiovascular disease to identify trends in place of death, such as the home, a hospital, nursing or long term care facility or an inpatient hospice facility.

The research appeared in the Journal of the American College of Cardiology.

Racial and socioeconomic disparities continue play a role in determining where a patient will receive end-of-life care, as Hispanic and African American patients were more likely than caucasians to die in the hospital. The difference between hospital deaths between African Americans and whites rose to 5.3% in 2017 from 4.9% in 2003.

“I think underutilization is a problem, not only of hospice care which is a clear here, but I think also underutilization of palliative care, which I think also leads to underutilization of hospice. From a disparities perspective and from an equity perspective it’s not surprising to see that underserved groups are still more likely to die in the hospital,” Arif Kamal, associate professor of medicine at Duke University and a member of the research team, told Hospice News. “There are concerns that there remains ongoing reticence to use hospice care by underserved minorities, particularly issues of distrust. It shows a real problem particularly from an equity issue that we want equity across end of life care and it’s really not there.”

Nearly 87% of Medicare decedents in 2016 were Caucasian, according to the National Hospice & Palliative Care Organization (NHPCO). Comparatively, slightly more than 8% were African-American; 2.1% were Hispanic, and 1.2% were Asian. That year, only 0.2% of Medicare decedents were Native American.

Patients who had higher education or socioeconomic status were also more likely to die at home. While this issue remains complex, some attention to social determinants of health could make a positive impact, which some payers and policymakers are beginning to recognize. Medicare Advantage plans, for example, in 2020 will pilot test some coverage of supplemental benefits designed to help patients stay in their homes.

The U.S. Centers for Medicare & Medicaid Services (CMS) will begin testing coverage of hospice through Medicare Advantage in 2021.

“We do know in the pilot programs that are going on through Medicare Advantage that there are expanded services now allowable, some transportation and meals and other home-based services,” Kamal said. “One could imagine that the future of hospice, which is not far off from here, could be an expanded hospice service that would allow for private duty nursing and other interventions that allow for a hospice type of care, but with additional logistical support that oftentimes patients would benefit from.”