title: Barriers to hospice care and referrals: survey of physicians' knowledge, attitudes, and perceptions in a health maintenance organization.
abstract: BACKGROUND
  Many proponents of hospice care believe that this service is underutilized.
  
  
  OBJECTIVE
  To determine physicians' perceptions of hospice utilization and of their own hospice referral pattern; their perceived and actual knowledge of appropriate hospice referral diagnoses; and perceived barriers to hospice referral.
  
  
  METHODS
  Surveys for anonymous response were distributed to 125 physicians in 2 internal medicine departments of a large not-for-profit health maintenance organization (HMO). Of these 125 physicians, 89% responded, including 91 staff physicians and 20 residents.
  
  
  RESULTS
  Of the 111 physician-respondents, 78% reported their belief that hospice care was underutilized; 84% were unable to identify appropriate hospice diagnoses; and 12% were aware of the "National Hospice Organization Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases." Difficulty of predicting death to within 6 months was cited by 37% as the foremost barrier to hospice referral. In addition, 28% expressed concern that patients or families would interpret hospice referral as a cost saving measure; 11% of respondents had been accused of using hospice referral for this purpose.
  
  
  CONCLUSIONS
  Our study-the first major survey of physician attitudes and practices regarding hospice utilization in an HMO setting-showed that barriers to hospice referral are similar to those in non-HMO settings; physicians have difficulty predicting life expectancy and lack knowledge of patient eligibility guidelines. Physician concern that patients or their family members would construe hospice referral as a cost-saving technique may be a barrier particularly troublesome in an HMO setting.
authors.affiliation: Department of Internal Medicine, Kaiser Permanente Medical Centers, Oakland, California 94611, USA. leslea.brickner@kp.org
authors.forename: Leslea
authors.initials: L
authors.lastname: Brickner
authors.forename: Kate
authors.initials: K
authors.lastname: Scannell
authors.forename: Stephanie
authors.initials: S
authors.lastname: Marquet
authors.forename: Lynn
authors.initials: L
authors.lastname: Ackerson
mesh_terms: D000328:Adult; D000367:Age Factors; D001291:Attitude of Health Personnel; D016009:Chi-Square Distribution; D004608:Eligibility Determination; D005260:Female; D006279:Health Maintenance Organizations; D017051:Hospice Care / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians'; D012017:Referral and Consultation; D013997:Time Factors