Oncologist Peer Comparisons as a Behavioral Science Strategy to Improve Hospice Utilization

Abstract

PURPOSE: Hospice utilization metrics are essential for any serious effort to improve end-of-life care in oncology. However, oncologists do not routinely receive these personalized reports. We evaluated whether a behavioral science intervention, using peer comparisons coupled with social norms, was associated with improvements in hospice use. METHODS: Oncologists at two academic practices of Johns Hopkins Medicine were randomly assigned to receive a peer comparison report by e-mail displaying individual hospice utilization metrics compared with top-performing peers or to receive no report. The data accrued for the intervention represented hospice utilization for the previous calendar year. The intervention period was from June 1, 2020, to December 30, 2020, and included oncologists from both the solid and hematologic malignancies programs. The primary outcome was the proportion of patients between groups with short hospice length of stay (LOS; defined as ≤ 7 days) after 6 months. Secondary outcomes included hospice referral rate, enrollment rate, and median LOS. RESULTS: Forty-seven oncologists participated. The percent of patients with a short hospice stay in the intervention group was lower (17.4%) compared with patients treated by physicians in the usual care group (46.3%, difference = 21.8%; 95% CI, 16.0 to 41.6; P < .001). Receipt of peer comparisons was associated with a greater likelihood of enrolling in hospice (73.7% v 42.8%; difference = 31.1%; 95% CI, 20.4 to 41.7; P < .001) and a longer hospice LOS (37.2 v 18.3 days; difference = 17.2; 95% CI, 8.8 to 25.7 days; P < .001). CONCLUSION: Peer comparisons improved hospice utilization metrics among a group of academic oncologists. Behavioral science offers one pragmatic strategy to overcome suboptimal oncologist decision-making biases related to hospice use.

End-of-life outcomes of advanced cancer patients enrolled in palliative care

“…There are multiple barriers to timely hospice referral. These include short visit time, overly optimistic prognostication, and status quo bias [29,30]. The observed bene t of PC consultation with respect to hospice enrollment in this study is likely related to the close integration of PC and hospice services and the signi cant overlap in philosophy of care between PC and hospice.…”

Precision Palliative Care as a Pragmatic Solution for a Care Delivery Problem

“…Insights from behavioral economics dictate that normative appeals to leadership endorsed standards can modify clinician behavior. 41,42 What does it say when clinicians receive monthly e-mails detailing their relative value unit reports and not the frequency of their panels unmet needs? It signals that volume trumps quality.…”

“…The EHR can (1) administer PROs for screening, (2) display supportive care needs for the multidisciplinary care team, (3) offer best practice alerts and/or nudges for referral, (4) default a referral order, and (5) provide a dashboard to track key metrics. 6,43 Successful work in behavioral science has already incentivized earlier referral to specialty PC, 11 hospice use, 41 and better conversations for seriously ill patients. 29,30,44 In conclusion, specialty PC has a major role in cancer care delivery, although it must be deployed in a staged and sustainable fashion, targeted to individual and caregiver needs.…”

Peer Comparison or Guideline-Based Feedback and Postsurgery Opioid Prescriptions

“…Although previous randomized clinical trials have shown that social norms can be used to reduce inappropriate antibiotic prescribing among primary care clinicians 13 and opioid prescribing in emergency departments, 14 there is limited high-quality evidence on whether feedback based on social norms can influence opioid prescribing in the surgical setting, which has a different structure of care and has the second highest opioid prescribing rate of any specialty after pain medicine. 15 , 16 Moreover, although recent research has examined the influence of either peer-based or guideline-based feedback (or both) on clinician behaviors, 17 , 18 , 19 , 20 , 21 little is known regarding how these directly compare to one another.…”