Oncologists Refer Patients Earlier to Hospice after Simple Quality Improvement Project

Treating Referrals as Quality Measures

By treating referral for hospice care as a quality measure, an Ohio healthcare system has seen the doubling of the hospice length of stay (LOS) among cancer patients referred by its oncologists in private practice, from a median of 19.7 days to a median of 39.6 days—and all within one year, according to a report on the project presented at the 2016 Palliative Care in Oncology Symposium in September.

"We needed to move an entire health system toward more routine, more systematic, and less variable care," explains project leader Charles F. von Gunten, MD, PhD, vice president of medical affairs, hospice and palliative medicine for OhioHealth, a system serving central Ohio. "It starts with the fact that hospice has been proven to be the best care at the end of life."

The key issue was how to reach all of the hospice eligible patients, notes von Gunten. "Our novel thought was whether we could treat referral for hospice care as a quality measure. "The researchers concluded that they could, with striking results. "Treating hospice care as a measure of quality showed that the length of stay doubled," says von Gunten. "This shows that something as simple as a quality improvement project can change behavior."

A Novel Quality Improvement Approach

The OhioHealth system contains clinical guidance councils, which set the standards of care for various specialties within the system. The oncology council is composed of medical, surgical, gynecological and radiation oncologists. This council was polled for a consensus on how long a patient with cancer should be enrolled in hospice. 64% of council members thought the median LOS for cancer patients should be 90 days; 20% thought is should be 45 days.

The council then sent letters to community medical oncologists (n = 18), informing them of the council's opinion that the optimum hospice LOS was 90 days and noting that the national median was only 43 days, based on current information from the National Hospice and Palliative Care Organization. The letter also included a graph illustrating each oncologist's current LOS for referred patients and how it compared with that of their peers.

"As a group, physicians are competitive. They like data and like knowing the numbers," notes von Gunten, who is himself a medical oncologist. "So, seeing their own performance and those of their peers, and being compared to benchmarks and standards—this was the core of our intervention."

Key Findings

• At baseline, the median LOS for cancer patients (n= 176) referred in 2014 by community oncologists was 19.7 days.
• Following the intervention, the median hospice LOS for patients (n = 133) referred in the first 10 months of 2015 was 39.6 days.

"The conclusion I reached from this study is that medical oncologists want to do the right thing," says von Gunten. "They are somewhat unsure of when to refer for hospice care and worry that they may refer too soon rather than too late. "By showing them the data, I was confirming that they were not referring patients too soon," he continues. "is project helped them overcome this concern."

As might be expected in a project conducted among real, practicing oncologists, there was a wide variation in results, notes von Gunten, with some improvements as great as an increase from 10 to 45 days for LOS, while some remained the same, and one practice even showed a decrease in hospice LOS (from 22 days down to 15 days).

There seemed to be no resentment at this intervention among the oncologists, observed von Gunten. "Our doctors are accustomed to getting quality data about a number of things, and this project fit the format, style, and tone of those other communications. I was surprised, but there was none of the feeling of 'you're attacking me; I'm doing the best I can.''

The measure is being repeated for oncologists for 2016, with plans for implementing the same intervention through the established clinical guidance councils for other specialists, such as pulmonologists, primary care physicians, hospitalists and cardiologists. "I can hardly wait to check the data later this year," he concludes.

Cosponsors of the 2016 Palliative Care in Oncology Symposium, subtitled "Patient-Centered Care across the Cancer Continuum," include the American Society of Clinical Oncology and the American Academy of Palliative Medicine, the American Society for Radiation Oncology and the Multinational Association of Supportive Care in Cancer.

Source: "A Quality Improvement Approach to Oncologist Referrals for Hospice Care,"2016 Palliative Care in Oncology Symposium, Abstract 45, presented September 10, 2016. Journal of Clinical Oncology; 34(suppl 26S; abstr 45). von Gunten CF; OhioHealth, Columbus, Ohio.