Measuring How Palliative Care is Delivered: Using Provider Sequences as a New Quality Signal

Context: Whether differences in program composition and provider staffing translate into meaningful variation in end-of-life (EOL) outcomes remains poorly understood, underscoring the need to examine how palliative care (PC) is delivered within hospitals. Objectives: This study applies a data-driven approach to understand longitudinal PC delivery of service across different types of providers (“provider sequence”) and explore whether these patterns of PC delivery correlate with EOL quality measures for patients with poor-prognosis advanced cancer. Methods: We conducted a retrospective cohort study using 2018–2019 Medicare fee-for-service claims. For each patient, we defined a provider sequence as a pair of consecutive PC encounters, classifying each encounter into a provider type: team specialist (TS), independent specialist (IS), and primary (P). For a given hospital, we aggregated the provider sequences of patients assigned to that hospital. We defined nine possible provider sequence patterns and quantified the proportion of provider sequence patterns within hospitals. We tested the association between the provider sequence patterns and three EOL quality measures: < one emergency department visit in the last 30 days, hospice use, and hospice enrollment ≥ three days. Results: Across 276 hospitals, a higher proportion of the IS→TS provider sequence pattern was associated with greater hospice use (β = 0.48; 95% confidence interval: 0.03, 0.93). For hospice enrollment ≥ three days, the TS→P provider sequence pattern had a negative association (β = −0.18; 95% confidence interval: −0.33, −0.04). Conclusion: A provider sequence quality signal may provide deeper insights into how palliative care is delivered within a hospital and may help explain EOL outcomes.