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Trends in hospice referral timing and location among individuals dying of ovarian cancer: persistence of missed opportunities
  1. Megan A Mullins1,
  2. Julie Ruterbusch2,
  3. Michele L Cote3,4,
  4. Shitanshu Uppal5 and
  5. Lauren P Wallner6,7
  1. 1Peter O’Donnell Jr. School of Public Health, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, Texas, USA
  2. 2Karmanos Cancer Insitute, Wayne State University, Detroit, Michigan, USA
  3. 3Simon Comprehensive Cancer Center, Indiana University, Indianapolis, Indiana, USA
  4. 4Richard M. Fairbanks School of Public Health, Indiana University Purdue University Indianapolis (IUPUI), Indianapolis, Indiana, USA
  5. 5Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
  6. 6Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
  7. 7Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
  1. Correspondence to Dr Megan A Mullins, UT Southwestern Medical Center, Dallas, TX 75390, USA; megan.mullins{at}


Objective To evaluate trends, racial disparities, and opportunities to improve the timing and location of hospice referral for women dying of ovarian cancer.

Methods This retrospective claims analysis included 4258 Medicare beneficiaries over age 66 diagnosed with ovarian cancer who survived at least 6 months after diagnosis, died between 2007 and 2016, and enrolled in a hospice. We examined trends in timing and clinical location (outpatient, inpatient hospital, nursing/long-term care, other) of hospice referrals and associations with patient race and ethnicity using multivariable multinomial logistic regression.

Results In this sample, 56% of hospice enrollees were referred to a hospice within a month of death, and referral timing did not vary by patient race. Referrals were most commonly inpatient hospital (1731 (41%) inpatient, 703 (17%) outpatient, 299 (7%) nursing/long-term care, 1525 (36%) other), with a median of 6 inpatient days prior to hospice enrollment. Only 17% of hospice referrals were made in an outpatient clinic, but participants had a median of 1.7 outpatient visits per month in the 6 months prior to hospice referral. Referral location varied by patient race, with non-Hispanic black people experiencing the most inpatient referrals (60%). Hospice referral timing and location trends did not change between 2007 and 2016. Compared with individuals referred to a hospice in an outpatient setting, individuals referred from an inpatient hospital setting had more than six times the odds of a referral in the last 3 days of life (OR=6.5, 95% CI 4.4 to 9.8) versus a referral more than 90 days before death.

Conclusion Timeliness of hospice referral is not improving over time despite opportunities for earlier referral across multiple clinical settings. Future work delineating how to capitalize on these opportunities is essential for improving the timeliness of hospice care.

  • ovarian cancer
  • palliative care

Data availability statement

Data may be obtained from a third party and are not publicly available. Data are available from SEER-Medicare upon approval of a written application.

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Data availability statement

Data may be obtained from a third party and are not publicly available. Data are available from SEER-Medicare upon approval of a written application.

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  • Contributors MAM, LPW, SU, and MLC developed the project idea and design. MAM performed the data analysis with assistance from JR. MAM wrote the manuscript with critical revision provided by all co-authors. MAM is guarantor.

  • Funding MAM received research support from the National Cancer Institute institutional training grant T32-CA-236621.

  • Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the National Cancer Institute.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.