One in six terminal cancer patients enroll in hospice only during their last three days of life, according to a new study from a team from the Perelman School of Medicine at the University of Pennsylvania. Their findings, published online in the Journal of Clinical Oncology, also reveal a profile of patients who may be most at risk of these late admissions.

The study comes amid the National Quality Forum and the American Society for Clinical Oncology’s joint endorsement of quality measures for end of life care in cancer patients. Eventually, Penn Medicine experts say, oncology practices and health systems may be measured and reimbursed in part on their percentage of patients who enroll near the end of life and be linked to pay-for-performance initiatives.

The team examined de-identified data from electronic medical records of 64,264 patients in 12 hospices in the Coalition of Hospices Organized to Investigate Comparative Effectiveness network from January 2008 to May 2013. Hospices spanned 11 states with censuses ranging from 400 to 1,700 patients per day. Of those 64,264 patients, 10,460 had a hospice stay of 3 days or fewer.

The study found several characteristics associated with hospice length of stay of three days or less, including being male, married, younger than 65, and of nonwhite ethnicity. Also, patients with blood cancers and liver cancer were more often than those of oral cancer to be among those admitted within the last three days of life.

Findings indicated that Medicaid and uninsured patients who enrolled in hospice typically did so earlier in the course of their illness than those with commercial insurance or Medicare. The researchers suggest these patterns illustrate which patients may be less able to afford out-of-pocket expenses associated with prolonged aggressive or experimental treatment, or that they may receive care in oncology practices that differ in their aggressiveness of care.

The researchers say the marriage association may be because marriage can provide caregiving structure – such as help with transportation to medical appointments and assistance with medication -- and emotional support and motivation to support continued treatment. And, they note, some married patients may prolong treatment for their spouse’s sake.

“Waiting until the final days of life to begin hospice can shortchange patients and their families – skipping over many benefits of hospice care and limiting the opportunity to improve patients’ quality of life during this stressful time,” said study co-author David Casarett, M.D., director of Hospice and Palliative care at Penn Medicine. “Our findings point to some reasons why patients may seek hospice care so late in the course of their illness, which we hope will enable us to improve transitions to hospice at a more beneficial point in their care.”

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