Founded at the Abramson Cancer Center at the University of Pennsylvania

Leveraging Peer Comparison to Improve Hospice Utilization

Evidence shows that hospice care for patients with end-stage cancer improves quality of life for patients and their caregivers, and yet a substantial number of patients do not receive hospice services. Of those who do enroll on hospice, almost one-third have a short length of stay (LOS) of less than 7 days. Limited time with the hospice care team is associated with increased emotional distress, worse symptom management, and greater financial toxicity. This underutilization of hospice care can in part be attributed to an overestimate of patient prognosis on the part of their oncologist as a result of optimism bias. Interventions informed by behavioral science can be utilized to positively influence oncologists’ decision-making. One such intervention is peer comparison, or relative social ranking, which is built on the premise that individuals care about how they compare with others. 


In this randomized trial leveraging peer comparisons to combat physician optimism bias and move beyond status quo, PC3I Innovation Faculty Ramy Sedhom, MD found improved hospice utilization metrics among a group of academic oncologists. Oncologists in the intervention group receive a single email with individualized data on their hospice utilization metrics compared with their top-performing peers. The primary outcome of the study was the proportion of patients short hospice length of stay between physicians randomized to the intervention and usual care group after 6 months.


The percent of patients with a short hospice stay treated by physicians in the intervention arm was lower (17.4%) compared to patients treated by physicians in the control arm (46.3%). Receipt of the peer comparison email also increased the likelihood of hospice enrollment (73.7% versus 42.8%) and increased length of stay (37 days versus 18 days). The findings support peer comparison as one strategy to overcome suboptimal decision-making biases related to hospice use. 



The study, “Oncologist Peer Comparisons as a Behavioral Science Strategy to Improve Hospice Utilization,” appeared in JCO Oncology Practice on April 4, 2022. The authors were: PC3I Faculty Ramy Sedhom, MD; PC3I Advisor Lawrence Shulman, MD; Amanda Blackford, Sc.M; Arjun Gupta, MBBS; Thomas J. Smith, MD; and Michael Carducci, MD. 

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