Hospice care has been shown to improve patients’ quality of life while reducing costs near death, but hospice services are chronically underused.
OhioHealth, however, has employed a quality improvement approach to address that conundrum — and with good success. Within less than a year, the average length of stay in hospice care for cancer patients nearly doubled.
“Medical oncologists want to do the right thing for their patients,” says Charles F. von Gunten, M.D., vice president of medical affairs, Hospice and Palliative Medicine for OhioHealth. “If you find a gap on something that people think is important and make it visible to them, they will change behavior.”
The evidence base for early palliative medicine and hospice care has been building since 2010, when researchers at Massachusetts General Hospital published data showing that early palliative care for patients with metastatic non-small cell lung cancer significantly improved their quality of life and mood, compared with a control group. Although the patients had less aggressive care at the end of life, they lived longer than patients who received standard care.
More recently, a study of Medicare beneficiaries with poor-prognosis cancers found that those who received hospice care had significantly lower rates of hospitalization, intensive care unit admission and invasive procedures at the end of life than a matched cohort that did not use hospice services. Moreover, the total cost of care for a patient enrolled in hospice was about $9,000 less than for those who did not.
Despite those findings, many patients who could benefit from hospice services do not receive them or are referred to hospice just days before death. In 2014, about 35 percent of hospice patients received care for seven days or fewer before they died or were discharged, says Jon Radulovic, vice president of communications for the National Hospice and Palliative Care Organization.
“Hospice is ideally suited for the final months of life, not the final days of life,” he says. “It can be difficult for hospice providers to figure out how to best meet the needs of the patients when they are basically providing brink-of-death care.”
At OhioHealth, a poll of the Oncology Clinical Guidance Council members found that two-thirds believed that cancer patients should ideally receive hospice care for 90 days, while 27 percent considered 45 days to be the ideal duration.
But the median length of stay for 176 cancer patients referred for hospice by OhioHealth oncologists in 2014 was only 21 days, von Gunten says. Through a quality improvement project the next year, the median length of stay in hospice care of an oncologist’s patients was introduced as a quality measure.
For starters, the 18 private-practice oncologists were notified of the Guidance Council’s opinion on length of stay. They also received a graph showing the median length of stay of their own patients in comparison to those of their peers.
Von Gunten described the physicians’ response to the data “heartwarming.”
“All the oncologists were surprised they were not performing well on hospice referrals,” he says. “They wouldn’t speak openly about it in meetings, but in individual conversations, many of them told me, ‘I thought I was doing better than that.’”
In the first 10 months of 2015, the median duration of hospice care for cancer patients increased to nearly 40 days, and the improvement has persisted since then, von Gunten says.