Abstract
Dear Editor:
A common narrative to explain short durations of hospice palliative care is that physicians are “against it.” Consequently, extensive education and marketing programs have been used over the past 35 years. Yet, in the United States the median length of service has been dropping. It is now at 17.4 days. 1 For our own program, serving 3000 patients per year in 20 counties in the central part of the State of Ohio, it was 10 days.
Since hospice palliative care has been proved to be the best care of patients in the last months of life 2 and physicians have been demonstrated to be systematically over-optimistic when formulating prognosis by 300%–500%, 3 an alternative explanation is the just don't know better. They also do not get individual feedback about their referral patterns. We hypothesized if physicians received information about their individual referral patterns in the context of their peers' opinion about optimal time receiving hospice palliative care, their individual referral patterns would improve.
We started by asking the Oncology Clinical Guidance Council, who represents all medical, radiation, surgical, and gynecological oncologists in the OhioHealth system, what the optimal time for a terminally ill patient with cancer should receive hospice palliative care at home. Sixty-seven percent said 90 days. Twenty-four percent said 45 days. They then received a letter signed by the oncologist chair of the clinical guidance council summarizing this opinion as well as indicating that, as a whole, the median length of service was 20 days. They were shown a bar chart of individual oncologist median length of service ranging from 5 to 150 days for patients referred in the previous year. The national median for cancer patients of 43 days was also shown. One year later, the same group of oncologists showed a median length of stay of 40 days. 4 They only received one letter.
We then expanded the method to other physicians using the same methodology by specialty. These data are shown in Figure 1. Significant improvements are seen in a number of specialty areas. For 1899 physicians referring at least 1 patient for hospice palliative care, the median length of stay improved from 15 to 27 days. There were no objections to the methodology. In contrast, physicians generally said, “I thought I was doing better than that.”
Median length of service in days by specialty of 1899 physicians referring at least 1 patient for hospice palliative care by year.
We conclude that a simple quality improvement approach increases the median length of time patients receive hospice palliative care. This suggests that the common narrative of physicians being “against” hospice palliative care is wrong. Furthermore, it supports the assertion that physicians agree that this hospice palliative care is the best way to care for patients, and are willing to improve their referral patterns in response to individual feedback. In our view, this paves the way for further efforts to improve physician prognostication and referral patterns.