Context: The literature predominately describes hospice utilization among Medicare recipients, with a limited number of reports describing use among all age groups. Objectives: This study aimed to describe and compare patterns of hospice use among decedents of all ages in Alabama using a population-based approach. Methods: We obtained death certificates for Alabama residents who died from January 1, 2002 to December 31, 2005 (n = 178,420). To ascertain hospice use, we linked death certificates to the hospice administering care using state-mandated listings of deaths reported by hospices. Additionally, each decedent's residence at death was geocoded and area-level socioeconomic status (SES) measures were added. Results: From 2002 to 2005, a total of 43,638 Alabamians died while under hospice care, representing a quarter (24.5%) of all deaths in the state. During this four-year span, the rate of hospice use increased by nearly 15% (22.2%-25.6%). As expected, rates of hospice use increased with age at death. For the SES indicators for poverty, education, and income, rates of hospice use increased as SES improved. However, this pattern was found to vary by race and metro/nonmetro status. Conclusions: In addition to revealing racial, geographic, and other disparities in hospice care across Alabama, our results indicate usage rates in Alabama trail behind those observed nationally. We also identified previously unreported interactions between race, urbanization level, and poverty classification. Future studies should explore whether such relationships exist elsewhere and the rationale for their occurrence. © 2011 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.