In this study of primary care physician referral practices within a managed care organization, the majority of physicians in this study reported referring at least one patient to the palliative care program in the prior year, and some reported referring multiple patients. Although physician beliefs were hypothesized to be associated with referral, we found instead that other physician characteristics - length of time with Kaiser and prior personal experience with palliative care - were associated with palliative care referral, although the latter did not reach statistical significance.
Only one other study has described primary care physician referral practices to outpatient palliative care, and also found that a majority of physicians (61%) made referrals.[26
] However, this study was a controlled trial of an outpatient palliative care consultation service and participating physicians were proactively encouraged to enroll eligible patients. In contrast, physicians in the current study were asked to report on their usual referral practices. Although social desirability pressures may bias self-report of practice patterns,[32
] the anonymity of the survey helped to minimize this bias.
Our findings suggest that there may have been more patients than were referred who could have benefitted from the palliative care program. Most physicians in this study reported that over 60% of their patient panel was comprised of patients with 2 or more chronic conditions but also reported referring only between one and four patients to the palliative care program. Although the presence of more than 2 chronic conditions is not by itself an absolute indicator of the need for palliative care, patients with multiple morbidities often face considerable physical and emotional symptom distress, increased functional dependence, and intense psychosocial support needs.[33
] This group of patients can benefit significantly from palliative care services such as targeted symptom management, social support and advance care planning. Although not all patients with multiple morbidities require palliative care, the large discrepancy between the number of referrals made and the number of patients with more than 2 chronic conditions suggests that physicians may need help in understanding and acknowledging the potential relevance of palliative care for this group of patients. Indeed, the primary reason reported by physicians for not referring any patients was the belief that they had no patients who were appropriate for palliative care. Because palliative care services have traditionally been provided in the hospice setting, physicians may be more likely to link the need for palliative care to limited life expectancy and perceive it as more appropriate for patients who are imminently dying, rather than the broader population of seriously ill patients who could benefit from palliative care services. This is supported by the finding that almost a third of the physicians who did not refer any patients to palliative care reported referring patients to hospice instead. Disentangling palliative care from the prevalent notion that it is appropriate only for imminently dying patients may serve to increase appropriate palliative care referrals in the outpatient setting.
The majority of physicians in this study held attitudes about palliative care that would seem to predispose them to refer patients to the program. Consistent with findings from other studies, a majority of physicians believed that palliative care was a valuable model[28
] but did not feel they had the ability to provide palliative care for their patients on their own.[36
] Additionally, the majority of physicians in this study did not believe that they held an exclusive caregiving role with their patients, suggesting they would be open to collaborating with and receiving help from the palliative care program in providing end of life care for their patients.
We did not find our hypothesized association between physician beliefs about palliative care and referral to the palliative care program. Although our study was only powered to find large associations (i.e., OR >= 2.0) between beliefs and referrals, there was no evidence of any trend toward association, suggesting that such an association was truly absent. A likely explanation for this finding is that simply holding beliefs about palliative care is not enough to motivate referral. We found that instead, an important determinant of referral was exposure to palliative care, through both personal experience and length of time at Kaiser. Gaining exposure to palliative care through personal experience may make it more likely for physicians to consider it for their own patients. Moreover, the finding that tenure at Kaiser was significantly associated with referral also suggests that longer exposure to the palliative care programs may increase physician awareness of and familiarity with palliative care, making them more likely to refer their patients to the program. An earlier study of 236 palliative care professionals reported similar findings, demonstrating that one of the main barriers to hospice referrals reported by respondents was physician lack of familiarity with hospice.[25
] Because outpatient palliative care programs are a relatively new and growing concept that physicians are only recently becoming familiar with,[21
] increased exposure to the programs may help motivate primary care physicians to consider it for their patients and thus increase referrals. One way to increase physician exposure to palliative care might be to increase the presence and visibility of the palliative care program in the outpatient setting, so that physicians are regularly reminded of the availability of palliative care services for their patients.
The association between Kaiser tenure and referral also suggests there may be an organizational environmental component related to referral practice. An early study of physician utilization behavior within prepaid group practices argued that the setting in which physicians work are a significant determinant of their use of clinical resources.[39
] In a more recent study evaluating the efficiency of healthcare providers with California, Wennberg, et al (2005) found striking variation in patterns of care across geographic regions and hospital systems, highlighting the potential influence of the work environment on physician practice.[40
] The organizational structure of an integrated health delivery system such as Kaiser Permanente emphasizes care coordination across settings and may facilitate greater collaboration between primary and specialty or ancillary service providers.[41
] More time spent working within that system may acclimatize physicians to refer their patients to services outside primary care. Although our findings suggest that it may take time to acclimatize physicians to collaborate with other services, there may be other more immediate ways to increase palliative care referral within any health delivery system. For example, implementing systems or processes that prompt physicians to consider palliative care in certain clinical situations may help to increase appropriate referrals in two ways: by reminding physicians of the availability of palliative care, and helping them to identify the broader population of multimorbid seriously ill patients for whom palliative care is beneficial. A prior randomized controlled trial of an interview tool aimed at helping physicians identify nursing home residents who might be eligible for hospice care based on their palliative care needs rather than their life expectancy significantly increased appropriate hospice referrals.[42
] A similar tool based on patient needs rather than on specific clinical characteristics is particularly relevant in the outpatient setting, where patients might not be imminently dying but could still benefit from palliative care services.
This study has several limitations. First, our sampling approach may have resulted in a selection bias. Out of the 345 primary care physicians working at the two medical centers, 170 were present at the meetings where the survey was administered. Attendance was limited largely by clinic schedules and physician vacation time. However, of the physicians who attended the meetings, 83% completed surveys, resulting in a total 42% response rate. This is consistent with other studies of physician attitudes on end of life care utilizing alternate sampling methods.[43
A second limitation was our inability to collect information on patient characteristics that may be associated with physician referral. Although we included proxy measures for burden of illness in lieu of chart data, these measures are subject to bias as they are based on the respondent’s ability to accurately recall and assess patient characteristics. Specifically, physician recognition of patient life expectancy is influenced by various personal and professional factors and may not reflect an objective assessment. However, these measures were used as control variables, and neither was significantly associated with the outcome.
A third limitation of this study is that we asked physicians to report any palliative care referrals made within the prior year, which may be subject to recall bias. A recall period of one year was used because given the historically low numbers of outpatient palliative care referrals, we concluded that respondents would be able to accurately recall and estimate any referrals made.
A final limitation is the potential lack of generalizability to other settings because of Kaiser’s unique integrated care delivery system which may facilitate collaboration between physicians and departments. KP physicians may be more likely to access the palliative care program than physicians in other healthcare organizations. Conclusions from this study may be more pronounced in non-HMO settings.
Despite these limitations, our quantitative study of the predictors of palliative care referral serves as a foundation for future research in this area. While beliefs about palliative care may still play a role in influencing physician practice, evidence from this study suggests that exposure to and familiarity with palliative care play an important role in influencing physician referral. Future efforts to increase appropriate referrals to outpatient palliative care should focus on reminding physicians about the availability of palliative care services and its relevance to seriously ill patients in the outpatient setting.