Variations Among Physicians in Hospice Referrals of Patients With Advanced Cancer

Abstract

Purpose: The benefits of hospice for patients with end-stage disease are well established. Although hospice use is increasing, a growing number of patients are enrolled for ≤ 7 days, a marker of poor quality of care and patient and family dissatisfaction. In this study, we examined variations in referrals among individuals and groups of physicians to assess a potential source of suboptimal hospice use. Methods: We conducted a retrospective chart review of 452 patients with advanced cancer referred to hospice from a comprehensive cancer center. We analyzed patient length of service (LOS) under hospice care, looking specifically at median LOS and percent of short enrollments (%LOS ≤ 7), to examine the variation between individual oncologists and divisions of oncologists. Results: Of 394 successfully referred patients, median LOS was 14.5 days and %LOS ≤ 7 was 32.5%, consistent with national data. There was significant interdivisional variation in LOS, both by overall distribution and %LOS ≤ 7 ( P < .01). In addition, there was dramatic variation in median LOS by individual physician (range, 4 to 88 days for physicians with five or more patients), indicating differences in hospice referral practices between providers (coefficient of variation > 125%). As one example, median LOS of physicians in the Division of Thoracic Malignancies varied from 4 to 33 days, despite similarities in patient population. Conclusion: Nearly one in three patients with cancer who used hospice had LOS ≤ 7 days, a marker of poor quality. There was significant LOS variability among different divisions and different individual physicians, suggesting a need for increased education and training to meet recommended guidelines.

Randomized trial of a hospice video educational tool for patients with advanced cancer and their caregivers

“…These findings are particularly relevant given the suboptimal use of hospice care noted among patients with advanced cancer 5,40 . Although hospice use is increasing in the United States, there has been a decline in the median LOS observed 5,12,40 . This is problematic because short hospice admissions are associated with poorer outcomes, including worse pain management, a higher incidence of depression, and lower perceived quality of EOL care among caregivers 9,10,41,42 .…”

Impact of Palliative Chemotherapy and Travel Distance on Hospice Referral in Patients With Stage IV Pancreatic Cancer: A Retrospective Analysis Within a Veterans Administration Medical Center

“…16 If hospice discussions remain delayed, physicians risk negatively impacts patient outcomes through increased psychological distress and pain. 11,24 Continuation of chemotherapy within 2 weeks of death has been associated with lower rates of hospice enrollment and shorter hospice LOS of <3 days, 25 depriving patients and families the opportunity to fully engage with the benefits of hospice. Significant variation in hospice referral patterns among oncologists practicing at an academic cancer center has been reported.…”

“…11 Utilization of hospice varied widely depending on the type of malignancy, but moreover differences were reported amid physicians who treat similar patient phenotypes, suggesting a gap in views, comfortability, or knowledge of end-of-life services. 11,16 The Kaplan-Meier analysis demonstrating shorter survival for the cohort of patients with mPDAC referred to hospice soon after diagnosis compared to those referred later suggests that physicians exercise appropriate clinical insight when limited survival is predicted. It is important to recognize that this difference in survival is also likely confounded by other factors including prescription of chemotherapy and performance status at diagnosis.…”

“…10 Thus, although there is overall increased hospice utilization in the past decade, timing of referral is not optimized as demonstrated by the decline in median length of service (LOS), the time for which hospice care is provided to a patient. 11 The Department of Veterans Affairs is dedicated to enhancing end-of-life care for veterans through improving access to home hospice via collaboration with community hospice centers. 12 Previous research indicated that veterans value less aggressive medical interventions compared to nonveterans at the end of life, 13,14 yet despite marked increased enrollment of veterans in home hospice, 12 they share similar trends with short LOS.…”

Association between physician US News & World Report medical school ranking and patient outcomes and costs of care: observational study

“…Given extensive evidence that practice patterns vary widely across physicians, 1 2 3 4 5 6 there is increasing interest in measuring the performance of individual physicians and understanding the determinants of physician level variation in patient outcomes and healthcare spending. Such knowledge may help design effective interventions to improve quality of care and reduce low value care.…”