Percentage of Patients who Died from Cancer Admitted to Hospice for Less than 3

Measure Specification

The Institute of Medicine’s report, Dying in America, advocates for measures to improve the quality and sustainability of end-of-life care, urging the federal government to “require public reporting on quality measures, outcomes, and costs regarding care near the end-of-life”. Hospice care is a form of palliative care for patients with a limited life expectancy of six months or less (according to Medicare hospice coverage criteria) who want to focus on quality of life and comfort rather than life-prolonging care.

Most insurance plans provide coverage for hospice. In 2021 the median length of hospice stay among Medicare beneficiaries was 17 days. Approximately 28% of hospice patients died or were discharged within 7 days of admission to hospice care. This is despite the fact that the hospice benefit is at least six months or longer if needed. This short length of stay means that the patient, family, and care team have limited time to get a plan of care in place before death, and that the focus tends to be more on the care of the imminently dying patient than living life to the fullest before the final decline in function.

Early referral to hospice increases the likelihood that pain and other symptoms will be managed more aggressively and therefore there will be less anxiety and distress at the end of life. One retrospective study of more than 64,000 patients with cancer who were admitted to hospice found that over 16% of those patients were only enrolled in the last three days of life or less.

The rate of patients who do not have a hospice referral prior to death continues to be higher than desired with one study reporting that more than 30% of patients were not referred and of those patients, only 7% had a documented discussion on the option of palliative care. Patients enrolled in hospice experience increased survival times along with a reduction in resource use such as aggressive end of life care and hospital admissions; benefits that increased the longer patients are enrolled in hospice.

This measure is based on ASCO and National Comprehensive Cancer Network (NCCN) Guidelines: 1. Clinicians should refer patients with advanced solid tumors and hematologic malignancies to specialized interdisciplinary palliative care teams that provide inpatient and outpatient care early in the course of disease, alongside active treatment of their cancer (Moderate, Strong) (ASCO, 2024).

2. Palliative care for patients with advanced cancer should be delivered through interdisciplinary palliative care teams, with consultation available in both outpatient and inpatient settings (Intermediate, Moderate) (ASCO, 2024). 3. Patients with advanced cancer should receive palliative care services, which may include a referral to a palliative care provider.

Essential components of palliative care include (Intermediate, Moderate) (ASCO 2024): • Rapport and relationship building with patient and family caregivers • Symptom, distress, and functional status management (eg, pain, dyspnea, fatigue, sleep disturbance, mood, nausea, or constipation) • Exploration of understanding and education about illness and prognosis • Clarification of treatment goals • Assessment and support of coping and spiritual needs • Assistance with medical decision making • Coordination with other care providers • Provision of referrals to other care providers as indicated 4.

Patients with months to weeks to live should be provided with guidance regarding the anticipated course of the disease. Physicians should reassess prognostic awareness and goals of therapy. As functional status worsens, these patients may become more concerned about the side effects of cancer-directed treatment and consider focusing their care on maintaining quality of life.

The option of discontinuing anticancer treatment not directly addressing a symptom complex and initiating goal-directed supportive care should be discussed, including referral to specialized palliative care services or hospice (Category 2A) (NCCN, 2024).In general, patients with weeks to days to live (eg, dying patients) and comfort-oriented goals should discontinue all treatments not directly contributing to patient comfort.

Intensive palliative care focusing on symptom management should be provided in addition to preparation for the dying process. Referral for hospice care should be placed, if not already done. (Category 2A) (NCCN, 2024).

This measure contains one strata defined by a single submission criteria. This measure produces a single performance rate. For the purposes of MIPS implementation, this patient-periodic measure should be submitted a minimum of once per patient per timeframe specified by the measure for the performance period. This is an inverse measure which means a lower calculated performance rate for this measure indicates better clinical care or control.

The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.