title: Variations Among Physicians in Hospice Referrals of Patients With Advanced Cancer.
abstract: 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.
  
  
  
  We conducted 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.
  
  
  
  Of 394 successfully referred patients, median LOS was 14.5 days and %LOS ≤ 7 was 32.5%, 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, median LOS of physicians in the Division of Thoracic Malignancies varied from 4 to 33 days, despite similarities in patient population.
  
  
  
  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.
authors.affiliation: The Johns Hopkins University School of Medicine; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center; Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Hospital, Baltimore; and Gilchrist Services, Hunt Valley, MD.
authors.forename: Xiao
authors.initials: X
authors.lastname: Wang
authors.affiliation: The Johns Hopkins University School of Medicine; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center; Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Hospital, Baltimore; and Gilchrist Services, Hunt Valley, MD.
authors.forename: Louise S
authors.initials: LS
authors.lastname: Knight
authors.affiliation: The Johns Hopkins University School of Medicine; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center; Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Hospital, Baltimore; and Gilchrist Services, Hunt Valley, MD.
authors.forename: Anne
authors.initials: A
authors.lastname: Evans
authors.affiliation: The Johns Hopkins University School of Medicine; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center; Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Hospital, Baltimore; and Gilchrist Services, Hunt Valley, MD.
authors.forename: Jiangxia
authors.initials: J
authors.lastname: Wang
authors.affiliation: The Johns Hopkins University School of Medicine; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center; Johns Hopkins Bloomberg School of Public Health; Johns Hopkins Hospital, Baltimore; and Gilchrist Services, Hunt Valley, MD.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Smith
mesh_terms: D017051:Hospice Care / Q000706:statistics & numerical data*; D006738:Hospices / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay; D009367:Neoplasm Staging; D009369:Neoplasms / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D012017:Referral and Consultation; D012189:Retrospective Studies