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Background: Variations in hospice use are not well understood.Objective: Assess whether care before death, including the types of physicians seen, number of outpatient visits, and hospitalizations, was associated with hospice use and the timing of enrollment.Design/setting: Observational study of a population-based sample of advanced breast cancer patients included in the Surveillance, Epidemiology, and End Results--Medicare database.Patients: There were 4,455 women aged > or =65 diagnosed with stage III/IV breast cancer during 1992-1999 who died before the end of 2001.Measurements: Hospice use and, among enrollees, enrollment within 2 weeks of death. Independent variables of interest included hospitalizations, outpatient visits, and physicians seen before death.Results: Adjusted hospice use rates were higher for hospitalized patients (45% if hospitalized for 1-7 days, 46% if 8-20 days, 35% if > or =21 days) than those not hospitalized (31%, P < 0.001). Adjusted rates were also higher among patients seeing a cancer specialist and primary care provider (PCP; 41%) and those seeing a cancer specialist and no PCP (38%) than among those seeing a PCP and no cancer specialist (30%) or neither type of physician (22%; P < 0.001). Hospice use also increased with increasing frequency of outpatient visits (P < 0.001). Hospitalizations, physicians seen, and visits were not associated with referral within 2 weeks of death (all P > or = 0.10).Discussion: Care before death is associated with hospice use among older women with advanced breast cancer. Additional research is needed to understand better how differences in patient characteristics and disease status influence cancer care before death and the role of various types of physicians in hospice referrals. [ABSTRACT FROM AUTHOR]