© 2019 American Academy of Hospice and Palliative Medicine Context: Hospice utilization is an end-of-life quality indicator. The Deep South has known disparities in palliative care that may affect hospice utilization. Objectives: The objective of this study was to evaluate the association among Deep South patient and hospital characteristics and hospice utilization. Methods: This retrospective cohort study evaluated patient and hospital characteristics associated with hospice among Medicare cancer decedents aged ≥65 years in 12 southeastern cancer centers between 2012 and 2015. We examined patient-level characteristics (age, race, gender, cancer type, and received patient navigation) and hospital-level characteristics (board-certified palliative physician, inpatient palliative care beds, and hospice ownership). Outcomes included hospice (within 90 vs. three days of death). Relative risks (RRs) and 95% CIs evaluated the association between patient- and hospital-level characteristics and hospice outcomes using generalized log-linear models with Poisson distribution and robust variance estimates. Results: Of 12,725 cancer decedents, 4142 (33%) did not utilize hospice. “No hospice” was associated with nonwhite (RR 1.24, 95% CI 1.17–1.32) and nonnavigated patients (RR 1.17, 95% CI 1.10–1.25), and those at a hospital with inpatient palliative care beds (RR 1.15, 95% CI 1.10–1.21). “Late hospice” (20%; n = 1458) was associated with being male (RR 1.31, 95% CI 1.19–1.44) and seen at a hospital without inpatient palliative care beds (RR 0.82, 95% CI 0.75–0.90). Conclusions: Hospice utilization differed by patient and hospital characteristics. Patients who were nonwhite, and nonnavigated, and hospitals with inpatient palliative care beds, were associated with no hospice. Research should focus on ways to improve hospice utilization in Deep South older cancer patients.