Physicians Are Biggest Influencer of Hospice Enrollment

Roxanne Nelson

June 17, 2015

Hospice enrollment may depend more on the physician than on the individual circumstances of the patient.

A new study published in the June issue of Health Affairs found that physician characteristics are the strongest predictor of whether a patient will be referred to hospice care, outweighing other known drivers, such as geographic location, patient age, race, sex, and comorbidities.

Specifically, the proportion of a physician's patients who were enrolled in hospice was a strong predictor of whether or not other patients being cared for by the same physician would also be enrolled in hospice.

After controlling for confounders that predict hospice enrollment, the authors found that patients would be 27% more likely to enroll in hospice if they received care from a physician in the top 10% of hospice use, compared with a physician in the bottom 10%.

Physician specialty and the type of medical facility also played a role in hospice use. Patients who were cared for by medical oncologists and those who received treatment in nonprofit hospitals were also significantly more likely than other patients to enroll in hospice.

"We found that the physician a patient sees is the single most important predictor we know of whether or not that patient enrolls in hospice care," said first author Ziad Obermeyer, MD, a physician researcher in the Department of Emergency Medicine at Brigham and Women's Hospital and an assistant professor of emergency medicine at Harvard Medical School, Boston.

"The take-home message is that doctors matter for their patients' choices regarding end-of-life care," he told Medscape Medical News. "And this implies two things ― one is that physicians need to take responsibility for asking patients about their preferences and inform them about options."

The second is that hospitals and health systems can set up systems to track use of high-quality end-of-life care and can help doctors to understand their own practices relative to local and national averages.

"A key piece of data that doctors need, and don't have currently, is better scientific tools to predict risk of dying, to help prompt and guide these discussions," said Dr Obermeyer.

Data on survival are currently available at two points: time of diagnosis, for which data come from national registries, and time of treatment, for which data come from clinical trials. "We have very little 'precision medicine' here, and little way to individualize predictions based on patients' unique disease trajectories," he said. "This is a key next step, which is increasingly feasible given advances in computational power and data availability."

Oncologists and Nonprofits

The authors note that a variety of factors predict whether or not patients will enroll in hospice, including demographic factors and those related to the healthcare system in general. However, these factors collectively explain only about 10% of the variation that has been observed in hospice use and end-of-life care patterns. Although many researchers and policy makers believe that individual physicians play a large role in hospice use, that belief has been difficult to substantiate empirically.

Dr Obermeyer and colleagues used a nationally representative sample of Medicare fee-for-service beneficiaries in the United States and identified patients who died from 2006 to 2011 following a poor-prognosis cancer diagnosis.

The cohort included 198,948 patients (mean age, 78 years; 88% white; 52% male). Two thirds (n = 131,757, 66%) were enrolled in hospice; individuals who were enrolled in hospice were more likely to be female, to be white, and to live in areas with higher median incomes compared with the patients who were not enrolled.

In addition to the patients, they also identified 70,073 physicians who cared for patients with poor-prognosis cancers; patient load was concentrated among a relatively small pool of physicians. The top 10% of physicians cared for nearly half (47%) of all patients included in the study.

Patient load also varied by specialty, and although medical and radiation oncologists constituted only 19% of the physicians in this cohort, they cared for 57% of all patients.

The authors identified several factors that were significantly associated with patient hospice enrollment. A higher incidence of comorbidities, older age, female sex, and white race were associated with hospice enrollment, but there were no real clear geographic patterns.

Patients who were treated by physicians who were predominantly linked to nonprofit hospitals were also were significantly more likely to enroll in hospice, compared with patients treated by physicians associated with for-profit facilities (OR, 0.93; 95% CI, 0.90 - 0.96).

Physician specialty was also significantly associated with the odds of a patient entering hospice. As compared with those being treated by medical oncologists (OR, 1.00), those primarily cared for by internists or family practitioners (OR, 0.90), medical subspecialists (OR, 0.77), or surgeons (OR 0.72) were significantly less likely to enroll in hospice.

Funding for this research was provided by the National Institutes of Health to Dr Obermeyer.

Health Aff. 215;34:993-1000. Abstract


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