Utilization of Hospice Services Vary by Individual Physician, Disease Type

Hospice referral for patients with advanced cancer continues to vary significantly by individual physician and treatment department, according to research published in Journal of Oncology Practice (published online February 21, 2017; doi:10.1200/JOP.2016.018093).


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Nearly one-third of observed patients received a late referral to hospice care and experienced a length-of-service (LOS) of 7 or fewer days, resulted showed.

“Hospice care has been associated with better quality of care, better survival in patients and surviving spouses, better perceptions of care by physicians and family members, and care that is most congruent with patient wishes,” wrote Thomas J Smith, MD, Harry J Duffey Family professor of palliative medicine and professor of oncology at Johns Hopkins Medicine (Baltimore, MD), and colleagues wrote. “Given these widespread benefits, the American Society of Clinical Oncology recommends a hospice information visit during the 6 months before death, as triggered by a change in treatment regimen or performance status.”

Despite these recommendations, prior research has shown low utilization of hospice services among patients with terminal cancer, as well as a preponderance of aggressive treatments in the end-of-life setting.

Dr Smith and colleagues retrospectively reviewed charts from 452 patients with advanced cancer who received a hospice referral. In order to determine the degree to which referrals varied by individual oncologists and divisions, the researchers examined median LOS and the percentage of enrollments lasting ≤ 7 days.

A total of 58 referred patients either declined hospice care or were ultimately deemed inappropriate for services. The median LOS among the remaining 394 patients was 14.5 days (range, 0-473). Approximately one-third of patients (32.5%; n = 128) had an LOS of ≤ 7 days; additionally, twenty patients (5.1%) died without utilizing hospice services. In contrast, thirty patients (7.6%) utilized hospice services for 90 days or more.

The proportion of patients with low hospice utilization was comparable to the national average (35.5%), whereas the percentage of high utilizers did not approach the national average of 19%.

The longest LOS was observed in patients with head and neck cancers (median, 37 days; interquartile range [IQR], 7-72), with hematologic cancer patients experiencing the shortest LOS (median, 7 days; IQR, 3-16). Patients with hematologic cancers also formed the highest percentage of patients with an average LOS of ≤ 7 days (54.1%).

The researchers observed notable physician-level variations in LOS, ranging from 0 to 157.5 days. When they limited the analysis to physicians with five or more patients, LOS ranged from 4 to 88 days. “Looking at individual divisions, all divisions surpassed 50% and many surpassed the 100% threshold,” Dr Smith and colleagues wrote. “Thus, there was significant variation in LOS among physicians, both overall and within specific divisions, despite sharing the same population of patients.” 

Study limitations identified by the researchers included the reliance on data from a single hospital and hospice service; the potential obfuscation of patient preferences through the use of LOS as the primary outcome measure; and the study’s inability to include data regarding newer cancer therapies—such as precision medicine—that may prolong active treatment in patients with advanced disease.

Dr Smith and colleagues indicated that they plan to re-audit their findings in 1 years’ time.—Cameron Kelsall