Structural Invisibility and Policy Decoupling: The Racialized Geography of End-of-Life Care Among Hip Fracture Decedents(1999–2020)

Background The shift from hospital-based to community-based end-of-life care has reshaped patterns of dying in the United States. However, whether this transformation has unfolded equitably across racial groups and geographic contexts remains insufficiently understood. This study examines racial and spatial disparities in place of death among older adults with hip fracture, with a focus on temporal dynamics and policy-relevant mechanisms. Methods We constructed a retrospective ecological cohort of 330,969 hip fracture decedents aged ≥ 65 years using U.S. mortality records from the CDC WONDER database (1999–2020). Outcomes included place of death (hospital vs. hospice/home). Temporal trends were assessed using joinpoint regression, and racial disparities were examined through two-way fixed effects models incorporating state-level Medicare Advantage penetration. Geospatial analyses were used to identify within- and between-state patterns of service availability. Results Overall hospice utilization increased substantially over the study period; however, these gains were unevenly distributed. Non-Hispanic White decedents experienced sustained growth in hospice deaths, while non-Hispanic Black decedents exhibited a marked post-2016 reversal, with hospice use declining sharply. Geographic analyses revealed extensive “service deserts,” where hospice utilization among Black decedents was effectively absent in many states despite adequate population size. Policy expansion in Medicare Advantage was associated with increased hospice use among White decedents but yielded substantially weaker effects among Black decedents, indicating a decoupling between coverage expansion and service access. Conclusions Racial disparities in place of death are deeply spatialized and persist despite broad policy expansion. These findings highlight the need for place-based approaches that address structural barriers to end-of-life care, moving beyond uniform coverage toward geographically and racially responsive interventions.