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Research ArticleOriginal Research

Regional Variation in Primary Care Involvement at the End of Life

Claire K. Ankuda, Stephen M. Petterson, Peter Wingrove and Andrew W. Bazemore
The Annals of Family Medicine January 2017, 15 (1) 63-67; DOI: https://doi.org/10.1370/afm.2002
Claire K. Ankuda
1Robert Wood Johnson Clinical Scholars Program, Family Medicine, University of Michigan Health System, Ann Arbor, Michigan
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  • For correspondence: cankuda@umich.edu
Stephen M. Petterson
2Robert Graham Center, Washington, DC
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Peter Wingrove
2Robert Graham Center, Washington, DC
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Andrew W. Bazemore
2Robert Graham Center, Washington, DC
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Abstract

PURPOSE Variation in end-of-life care in the United States is frequently driven by the health care system. We assessed the association of primary care physician involvement at the end of life with end-of-life care patterns.

METHODS We analyzed 2010 Medicare Part B claims data for US hospital referral regions (HRRs). The independent variable was the ratio of primary care physicians to specialist visits in the last 6 months of life. Dependent variables included the rate of hospital deaths, hospital and intensive care use in the last 6 months of life, percentage of patients seen by more than 10 physicians, and Medicare spending in the last 2 years of life. Robust linear regression analysis was used to measure the association of primary care physician involvement at the end of life with the outcome variables, adjusting for regional characteristics.

RESULTS We assessed 306 HRRs, capturing 1,107,702 Medicare Part B beneficiaries with chronic disease who died. The interquartile range of the HRR ratio of primary care to specialist end-of-life visits was 0.77 to 1.21. HRRs with high vs low primary care physician involvement at the end of life had significantly different patient, population, and health system characteristics. Adjusting for these differences, HRRs with the greatest primary care physician involvement had lower Medicare spending in the last 2 years of life ($65,160 vs $69,030; P = .003) and fewer intensive care unit days in the last 6 months of life (2.90 vs 4.29; P <.001), but also less hospice enrollment (44.5% of decedents vs 50.4%; P = .004).

CONCLUSIONS Regions with greater primary care physician involvement in end-of-life care have overall less intensive end-of-life care.

  • palliative care
  • end-of-life care
  • primary care
  • healthcare services research
  • hospice
  • death
  • family practice
  • internal medicine

Footnotes

  • Conflicts of interest: authors report none.

  • Funding support: This study was supported by the Robert Graham Center Visiting Scholars Program.

  • Previous presentations: Findings were previously presented at the North American Primary Care Research Group (NAPCRG) Annual Meeting; October 24–28, 2015; Cancun, Mexico.

  • Received for publication August 7, 2015.
  • Revision received July 18, 2016.
  • Accepted for publication August 1, 2016.
  • © 2017 Annals of Family Medicine, Inc.
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The Annals of Family Medicine: 15 (1)
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Vol. 15, Issue 1
January/February 2017
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Regional Variation in Primary Care Involvement at the End of Life
Claire K. Ankuda, Stephen M. Petterson, Peter Wingrove, Andrew W. Bazemore
The Annals of Family Medicine Jan 2017, 15 (1) 63-67; DOI: 10.1370/afm.2002

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Regional Variation in Primary Care Involvement at the End of Life
Claire K. Ankuda, Stephen M. Petterson, Peter Wingrove, Andrew W. Bazemore
The Annals of Family Medicine Jan 2017, 15 (1) 63-67; DOI: 10.1370/afm.2002
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Subjects

  • Person groups:
    • Older adults
  • Methods:
    • Quantitative methods
  • Other research types:
    • Health services
  • Core values of primary care:
    • Access
    • Relationship

Keywords

  • palliative care
  • end-of-life care
  • primary care
  • healthcare services research
  • hospice
  • death
  • family practice
  • internal medicine

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