Hospitalists and hospice referrals

A study author discusses why hospice rates, and referrals by hospitalists, may be increasing.


Patients near the end of life are increasingly likely to go to hospice and to be sent there by hospitalists, a recent study found. Using Medicare data, lead author Claire K. Ankuda, MD, MPH, and colleagues studied hospice referral rates for more than 105,000 hospitalized nursing home residents with advanced cognitive impairment at discharge.

In their results, which were published in the August Journal of the American Geriatrics Society, the hospice referral rate for the cohort increased over time, from 2.8% in 2000 to 11.2% in 2010. One variable of note was the type of attending physician: Hospitalists were 17% more likely than nonhospitalists to refer patients to hospice. Dr. Ankuda, a palliative care fellow at the Icahn School of Medicine at Mount Sinai in New York City, recently spoke with ACP Hospitalist about these findings.

Q: What led you to study this issue?

A: There have been lots of studies that have shown that families are very satisfied with the kind of care provided in hospice, that the patient experience is better, and that hospice saves costs. . . . But . . . [research] has shown that hospice is unequally available to people around the United States. Part of that is definitely because of patient preference, but a lot of that is because of physicians and which physicians refer to hospice and which don't.

Q: Were you surprised at the two main findings of the study?

A: The increase in hospice referrals I expected because we know that there have been many, many more hospices built in the last 20 years, and in the 10 years of this study, there were huge increases in the number of hospices around. I think part of that is the economics—hospice, for several reasons, just became a growing industry—and there are growing incentives [on the hospital side] for patients to not die in the hospital and to not have readmissions. Although this study was actually primarily before that time, I think some of those wheels were in motion of hospitals looking at what was going on with their care and thinking more about hospice as an option to offer patients. And then culturally, I think part of it is that hospice and palliative care have grown dramatically in terms of people's awareness of it and patients' and families' awareness of it.

I was surprised to see the hospitalist effect. There is some pretty interesting work that has shown that continuity of care (in other words, being a primary care physician who knows a patient outside of the hospital) leads to better outcomes at the end of life. However, there's other work showing that sometimes having fresh eyes, like a hospitalist who doesn't know a patient outside the hospital might have, might actually increase the chance of hospice referral because . . . there's some evidence that you're more likely to be accurate in prognosticating how long they have to live. Part of that is probably just emotional, and part of that is if you see someone every day, sometimes you don't see the changes as much. We did show in this study that physicians who had seen the patient before they came to the hospital but not during the hospital stay were [22%] less likely to refer to hospice than the doctors who were new to the patient in the hospital.

Q: What are some other potential reasons why hospitalists might be more likely to refer?

A: The first obvious, glaring, and in some ways least interesting reason why is that hospitalists are younger and more fresh out of training, so possibly they've gotten more education about hospice and palliative care. We don't know that because we don't know the age of the doctors, but we do know that hospitalists are younger. I think hospitalists are probably far more attuned to hospital quality improvement efforts and hospital systems because all of their work is in the hospital.

For one of our subanalyses, we looked at whether the difference between [referrals from] a hospitalist and a generalist was explained by people being in hospitals that had really increased their use of hospitalists, and we found that that explained a lot of what we were seeing. I think what that means is almost a herd effect of hospitals who are, as a culture, hiring lots of hospitalists and aggressively focusing on quality improvement measures. Dying in the hospital is one of those, and increasing hospice referrals is a main mechanism of shifting that outcome. I don't mean to make it sound like they're doing it to just improve the numbers—in this very sick cohort, I think using hospice to provide some more home support, as long as it's in line with patients' and families' goals, is a very reasonable way to improve outcomes and improve the quality of care for patients.

Q: What are the implications of your findings?

A: This study was looking at the difference between physician types, but for all physician types in this study, the rates of hospice use were still really low. This cohort was very sick. In one year, 70% of them were dead. Hospitalists did the best at hospice referral, but they were still only referring 14% of these people. I think that's interesting to understand that hospitalists are doing better at this—why, and how can we learn from that?—but I think all of us still have a lot to go in terms of making sure that people are aging in place and dying the way they would want. For a lot of patients, that is at home.

Q: What tips do you have for hospitalists?

A: There is a lot of confusion that I see among hospitalists and other physicians on things like who qualifies for hospice and what hospice can and can't help with in terms of support at home. Hospices themselves are excellent resources that can be pulled in to educate patients and families about this. I've seen from other work I've done . . . [that] there would be very effective partnerships between, for example, oncology clinics and hospices to educate physicians, nurses, patients, and families. I think a lot more of that could probably happen in hospitals.