# State-Level Variability in Location of Death of Patients with End-Stage Liver Disease

## TL;DR

This study examines where patients with end-stage liver disease and liver cancer die in the US, finding racial and geographic differences in death locations.

## Contribution

The study identifies state-level variability and racial disparities in end-of-life care settings for ESLD and HCC patients.

## Key findings

- Black and Hispanic/Latino patients with ESLD and HCC more frequently die in inpatient facilities compared to White patients.
- A positive correlation exists between hospice agency numbers and home deaths among White and Hispanic/Latino patients.
- Geographic variation in death locations persists despite declining in-hospital deaths overall.

## Abstract

Although deaths from end-stage liver disease (ESLD) and hepatocellular carcinoma (HCC) in the United States increasingly occur at home or in hospice, inpatient medical facility deaths remain high. Despite the decrease in in-hospital deaths for all causes, non-White decedents are more likely than White decedents to die in a hospital setting. This study aimed to determine state-level variability in the location of death among patients with ESLD and HCC and to assess racial/ethnic differences in these patterns, focusing on Black, White, and Hispanic/Latino patients.

A retrospective cross-sectional analysis was conducted using 2018–2022 data from the Centers for Disease Control and Prevention Wide-Ranging OnLine Data for Epidemiologic Research. The proportion of patients with ESLD, HCC, and both conditions who died at an inpatient medical facility, home, hospice facilities, and a combination of both home and hospice was calculated, stratified by race/ethnicity. Mapping was utilized to compare these proportions across the US.

There was notable geographic variation in the location of death across all groups. Black and Hispanic/Latino patients with ESLD and HCC more frequently died in inpatient facilities compared to White patients. A statistically significant positive correlation was observed between the number of registered hospice agencies in a state and the proportion of deaths occurring at home among White (Spearman’s ρ = 0.33, p = 0.02) and Hispanic/Latino patients (Spearman’s ρ = 0.38, p = 0.01).

Future research should investigate factors driving interstate variability and racial differences in end-of-life care for ESLD and HCC patients, which may include hospice availability and the presence of palliative care laws. Strategies to reduce these differences and enhance access to quality end-of-life care for all, particularly for racial/ethnic minorities, are needed.

The online version contains supplementary material available at 10.1007/s10620-025-09433-w.