Article Figures & Data
Tables
- Table 1
Characteristics of Hospital Referral Regions by Quartile of Mean Ratio of Primary Care to Specialist Visits in the Last 6 Months of Life
Quartile of PCP Involvement Measure First (Lowest) (n = 76) Second (n = 77) Third (n = 77) Fourth (Highest) (n = 76) P Value Outcomes Deaths of chronically ill beneficiaries, No.a 376,118 303,772 242,084 185,728 – Ratio of PCP:specialist visits in the last 6 mo of life (range) 0.66 (0.38–0.77) 0.88 (0.78–0.98) 1.08 (0.98–1.21) 1.42 (1.21–2.55) – Patient characteristics Mean age, y 72.11 71.31 70.97 71.08 <.001 Female, % 56.0 55.5 55.2 54.3 <.001 African American, % 11.4 10.2 7.9 3.6 <.001 HCC score, mean 1.04 0.99 0.97 0.92 <.001 Population characteristics Below FPL, % 13.9 16.1 15.9 15.5 .005 Urban, % 92.8 79.1 68.3 55.1 <.001 Obese, % 25.2 27.5 27.3 27.4 <.001 History of stroke, % 4.5 3.9 3.8 3.3 <.001 Health care supply characteristics Medical doctors per 100,000, No. 203.23 187.50 188.70 192.90 .10 PCPs per 100,000, No. 51.10 49.57 56.42 63.18 <.001 Specialists per 100,000, No. 130.23 118.59 116.60 114.96 <.001 Hospital beds per 1,000, No. 50.74 43.23 41.05 37.67 <.001 ICU beds per 1,000, No. 21.49 15.95 12.24 10.24 <.001 FPL = federal poverty limit; HCC = hierarchical condition category; HRR = hospital referral region; ICU = intensive care unit; PCP = primary care physician.
Note: There were 306 HRRs, capturing 1,107,702 total decedents in 2010.
↵a Chronically ill Medicare beneficiaries, deceased in 2010.
- Table 2
End-of-Life Care in HRRs by Quartile of Primary Care Involvement in the Last 6 Months of Life
Quartile of HRRs by Ratio of Primary Care to Specialist Visits in the Last 6 Months of Life Measure First (Least PCP Involvement) (n = 76) Second (n = 76) Third (n = 76) Fourth (Most PCP Involvement) (n = 77) P Valuea Deaths occurring in hospitals, % (95% CI) 24.5 (23.8–25.1) 24.0 (23.5–24.5) 24.0 (23.5–24.5) 24.0 (23.4–24.6) .55 Decedents enrolled in hospice, % (95% CI) 50.4 (49.1–51.7) 48.1 (47.2–49.1) 47.9 (46.9–48.9) 44.5 (43.3–45.7) .004 Patients seeing ≥10 physicians in their last 6 mo of life, % (95% CI) 42.4 (41.6–43.1) 37.8 (37.2–38.4) 36.9 (36.3–37.6) 37.0 (36.3–37.8) <.001 Patients receiving ICU care during their final hospital admission, % (95% CI) 17.5 (17.0–17.9) 15.9 (15.5–16.2) 15.2 (14.9–15.6) 14.5 (14.1–14.9) <.001 Hospital days in the last 6 mo of life, No. (95% CI) 9.76 (9.57–9.96) 9.10 (8.95–9.25) 9.00 (8.84–9.15) 9.15 (8.97–9.33) .10 ICU days in the last 6 mo of life, No. (95% CI) 4.29 (4.13–4.44) 3.63 (3.51–3.75) 3.07 (2.95–3.20) 2.90 (2.76–3.05) <.001 Total Medicare spending per decedent in last 2 y of life, US$1,000b 69.03 (68.08–69.98) 66.70 (65.96–67.44) 64.07 (63.32–64.83) 65.16 (64.27–66.05) .003 HRR = hospital referral region; ICU = intensive care unit; PCP = primary care physician.
Note: Adjusted for the HRR percentage of population below the federal poverty limit, percentage of Medicare beneficiaries reporting they were African American, percentage of beneficiaries who were female, average age of Medicare beneficiaries, average hierarchical condition category score of Medicare beneficiaries, percentage of HRR that is urban, obesity rate, stroke rate, and regional density of specialist physicians.
↵a Testing the ratio of primary care to specialist visits as a continuous variable as opposed to quartiles of the ratio.
↵b In 2010 dollars.
Additional Files
The Article in Brief
Regional Variation in Primary Care Involvement at the End of Life
Andrew W. Bazemore , and colleagues
Background Primary care improves patient care through coordination of care and services, continuity of relationships, and comprehensiveness of practice, but more information is needed about primary care physician (PCP) participation in end of life care. This study examines regional variation in PCP involvement in the end of life and the association of such involvement with end of life outcomes.
What This Study Found Regions of the country with greater primary care physician involvement in the last 6 months of life have lower-intensity, lower-cost end-of-life care. Chronically ill adults in regions with greater primary care physician involvement have less care in the intensive care unit in their last 6 months of life and are less likely to have more than 10 physicians in their care. These regions also have less costly end-of-life care, despite lower rates of hospice use.
Implications
- These findings can help us better understand and optimize the role of primary care physicians in care at the end of life in order to both improve the care of the dying and reduce unnecessary and costly intensive care.
