SAN FRANCISCO — Patients with cancer frequently enter hospice care later rather than sooner, but a relatively simple strategy was able to double the length of service from oncologist referral.
In the OhioHealth hospital system, the median length of hospice stay at baseline was 19.7 days. But when hospice care was treated as a measure of quality, the number jumped to 39.6 days.
A simple quality improvement approach to improving hospice length of service by oncologists allowed the length of stay to literally double, to the point of reaching the national median within 1 year, explained Charles F. Von Gunten, MD, PhD, vice president medical affairs, hospice and palliative medicine, OhioHealth, Columbus.
Dr Von Gunten presented the findings from his study here at the Palliative Care in Oncology Symposium (PCOS) 2016.
"Hospice care is proven to be the best care at the end of life, but the key issue is how to reach all eligible patients," he said. "Since we know that it improves quality and lowers cost, then can we treat referral to hospice as a quality measure?"
He joked that because he is a medical oncologist he can make comments about his "tribe."
"As I go around the hospitals, conferences, and so on, I hear comments about why oncologists don't refer patients to hospice care," Dr Von Gunten said.
These included: "Medical oncologists make late referrals because they make money from chemotherapy. Or they don't tell the truth and don't tell patients their prognosis. They are cold, heartless and don't care, and they are anti–palliative care and anti-hospice."
If that's really the model and the broad perception, then that is somewhat immovable, Dr Von Gunten noted. "But what if it's really this: Medical oncologists are genuinely uncertain about when to refer for hospice care. They want to do the right thing and are unsure if what they are doing is right."
"And that's the shift, and that's the basis for this project," he pointed out.
The idea was to look at hospice referral as a quality improvement measure, where physicians could see their own performance as well as that of their peers, along with benchmarks and standards.
The OhioHealth system is composed of private practices, and at baseline, the average length of hospice stay was 21 days, compared with a national average of about 44 days. "Although it varied by practice there is a gap, and that is the fodder for a project where the objective is to close the gap," Dr Von Gunten said.
Dr Von Gunten brought his idea to the Oncology Clinical Guidance Council, which is composed of medical, surgical, gynecologic, and radiation oncologists who set the standards of care for the OhioHealth system that serves central Ohio.
The Council was polled for consensus on how long a patient with cancer should be enrolled in hospice care; 67% felt that the ideal stay was 90 days, while 27% thought it was 45 days.
The median length of stay of patients referred by 18 medical oncologists from their offices to OhioHealth hospice for calendar year 2014 was obtained, and a letter from the chairs of the Oncology Clinical Guidance Council was sent to each medical oncologist noting the council's opinion about optimal length of stay, the length of stay reported by the National Hospice and Palliative Care Organization, and the median length of stay of all patients referred by OhioHealth oncologists.
A chart that graphed the median length of stay by each oncologist was mailed to all practices. One year later, for calendar year 2015, the measurement of median length of stay by oncologist was repeated.
At the beginning of the project, the median length of stay for 176 patients with cancer referred to hospice in 2014 was 19.7 days. But during the first 10 months of 2015, the median length of stay for 133 patients was 39.6 days.
"Treating hospice care as a measure of quality showed that the length of stay doubled," said Dr Von Gunten. "This shows that something as simple as a QI [quality improvement] project can change behavior."
Among individual physicians and practices, there was wide variation. Some practices showed improvement while others did not.
One physician, for example, went from 10 days to 45 days, while another practice went from about 22 days down to 15 days.
But this variation does fit real life, he emphasized. "And this is a real picture of medical oncologists."
The results were presented to the Guidance Council, and the measure was repeated for this year.
"This is a relatively minor intervention," Dr Von Gunten summarized. "Private practice oncologists doubled their hospice length of stay after only 1 year. Treating it as a quality measure is acceptable and actionable."
There are Clinical Guidance Councils for other specialties — pulmonologists, primary care physicians, hospitalists, and cardiologists — and they have implemented the same intervention.
"I can hardly wait to check the data later this year," Dr Von Gunten concluded.
Commenting on the study, Petra Feyer, MD, PhD, Vivantes Clinics Berlin Neukoelln, Germany, noted that even though hospice care is the best care at the end of life and improves quality and lowers cost, a key issue is reaching all eligible patients.
It is unclear why medical oncologists were referring patients to hospice late in the illness trajectory, she noted, with varying perceptions as to the reasons.
"The medical oncologists want to do the right thing, but maybe they are not doing the best thing and are genuinely uncertain about when to refer to hospice," Dr. Feyer said, echoing Dr Von Gunten.
"But this study proved that education, survey, and communication can improve the goal of early hospice care in our patients," she added. "Survey and comparison with the standard of care leads to an improvement in quality of care."
Dr Von Gunten reports relationships with Otsuka, Salix, and AstraZeneca. Dr Feyer reports relationships with Amgen, Eusapharma, Merck Sharp & Dohme, Merck/Serono, Otsuka, TEVA, Amgen Dompe, and MSD/Merck.
Palliative Care in Oncology Symposium (PCOS) 2016. Abstract 45. Presented September 10, 2016.
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