Association between attending physicians’ rates of referral to palliative care and location of death in hospitalized adults with serious illness: a population-based cohort study

Background — Patients who receive palliative care are less likely to die in hospital.

Objective — To measure the association between physician rates of referral to palliative care and location of death in hospitalized adults with serious illness.

Research Design — Population-based decedent cohort study using linked health administrative data in Ontario, Canada.

Subjects — A total of 7866 physicians paired with 130,862 hospitalized adults in their last year of life who died of serious illness between 2010 and 2016.

Exposure — Physician annual rate of referral to palliative care (high, average, low).

Measures — Odds of death in hospital versus home, adjusted for patient characteristics.

Results — There was nearly 4-fold variation in the proportion of patients receiving palliative care during follow-up based on attending physician referral rates: high 42.4% (n=24,433), average 24.7% (n=10,772), low 10.7% (n=6721). Referral to palliative care was also associated with being referred by palliative care specialists and in urban teaching hospitals. The proportion of patients who died in hospital according to physician referral rate were 47.7% (high), 50.1% (average), and 52.8% (low). Hospitalized patients cared for by a physician who referred to palliative care at a high rate had lower risk of dying in hospital than at home compared with patients who were referred by a physician with an average rate of referral [adjusted odds ratio 0.91; 95% confidence interval, 0.86-0.95; number needed to treat=57 (interquartile range 41-92)] and by a physician with a low rate of referral [adjusted odds ratio 0.81; 95% confidence interval, 0.77-0.84; number needed to treat =28 patients (interquartile range 23-44)].

Conclusions and Relevance — An attending physicians' rates of referral to palliative care is associated with a lower risk of dying in hospital. Therefore, patients who are cared for by physicians with higher rates of referral to palliative care are less likely to die in hospital and more likely to die at home. Standardizing referral to palliative care may help reduce physician-level variation as a barrier to access.