Variations among physicians in hospice referrals of patients with advanced cancer

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 Weconducted 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 Of394successfully referred patients, medianLOSwas14.5 days and%LOS#7was32.5%, 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, medianLOSof 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.