October 2016, Vol. 5, No. 8

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Quality Improvement Project Doubles Hospice Length of Stay

Palliative Care

A simple quality improvement project to increase duration of hospice care for patients has doubled hospice length of stay, reaching the national median in 1 year. Conducted within the OhioHealth system, this relatively minor intervention suggests that oncologists can change their behavior and refer patients earlier to hospice care.

“We needed to move an entire health system toward more routine, more systematic, and less variable,” said Charles F. Von Gunten, MD, PhD, Vice President, Medical Affairs, Hospice and Palliative Medicine for OhioHealth. “It starts with the fact that hospice has been proven to be the best care at the end of life. We also know that enrollment in hospice lowers cost.”

As Dr Von Gunten described at the 2016 Palliative Care in Oncology Symposium, the key issue was reaching all eligible patients. “Our novel thought,” he said, “was to treat referral for hospice care as a quality measure.”

Intervention Design

A survey of the Oncology Clinical Guidance Council, which sets standards of care for the OhioHealth system in central Ohio, found that 67% of council members believed the ideal duration of hospice care for cancer patients was 90 days, with 27% indicating it should be 45 days. Information obtained from the National Hospice and Palliative Care Organization (NHPCO) by Dr Von Gunten showed the national median to be 44 days.

However, as Dr Von Gunten reported, the median length of stay for patients (N = 176) referred by the 18 private-practice medical oncologists in the OhioHealth system was only 21 days in 2014.

“As expected, we saw variability,” he said, “but overall, a big gap was seen, which was fodder for a quality improvement project.”

In order to improve these numbers, a letter from the council chairs was sent to each medical oncologist noting the council’s opinion about optimal length of stay, the NHPCO national median, and the median length of stay of all patients referred by OhioHealth oncologists. More importantly, said Dr Von Gunten, the oncologists also received a graph detailing the median length of stay of their own patients and those of their peers. One year later, for calendar year 2015, the measurement of median length of stay by oncologist was repeated.


The intervention resulted in much timelier referrals; median duration of hospice care increased to 39.6 days for the 133 patients referred in the first 10 months of 2015. A simple quality improvement approach to improving hospice length of service by oncologists yielded a doubling, he said.

The intervention was not a uniform success. A few physicians failed to improve, and 1 actually decreased. Nevertheless, said Dr Von Gunten, when considered as a whole, the data support the idea that oncologists genuinely want to do right by their patients but are just uncertain about the proper timing for referral to hospice care.

“The major concern among these oncologists was that they were referring patients too early,” he said. “Therefore, they often put off these conversations. This project has helped them overcome this concern.”

Dr Von Gunten and the council have sent another letter to oncologists detailing these results and will repeat the measurements again next year. He also plans to extend this quality improvement measure to other specialties.

“As a group, physicians are competitive,” he said. “Seeing your own performance alongside those of your peers and being compared to benchmarks and standards is the key to changing behavior.”

“This simple intervention also shows that treating hospice care as a quality measure is acceptable and actionable,” he concluded.

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