BackgroundWhile most individuals wish to die at home, the reality is that most will die in hospital.AimTo determine whether receiving a physician home visit near the end-of-life is associated with lower odds of death in a hospital.DesignObservational retrospective cohort study, examining location of death and health care in the last year of life.Setting/ParticipantsPopulation-level study of Ontarians, a Canadian province with over 13 million residents. All decedents from April 1, 2010 to March 31, 2013 (n = 264,754)ResultsMore than half of 264,754 decedents died in hospital: 45.7% died in an acute care hospital and 7.7% in complex continuing care. After adjustment for multiple factors–including patient illness, home care services, and days of being at home–receiving at least one physician home visit from a non-palliative care physician was associated with a 47% decreased odds (odds-ratio, 0.53; 95%CI: 0.51–0.55) of dying in a hospital. When a palliative care physician specialist was involved, the overall odds declined by 59% (odds ratio, 0.41; 95%CI: 0.39–0.43). The same model, adjusting for physician home visits, showed that receiving palliative home care was associated with a similar reduction (odds ratio, 0.49; 95%CI: 0.47–0.51).ConclusionLocation of death is strongly associated with end-of-life health care in the home. Less than one-third of the population, however, received end-of-life home care or a physician visit in their last year of life, revealing large room for improvement.

Background:To enable coordinated palliative care delivery, all clinicians should have basic palliative care skill sets (‘generalist palliative care’). Specialists should have skills for managing complex and difficult cases (‘specialist palliative care’) and co-exist to support generalists through consultation care and transfer of care. Little information exists about the actual mixes of generalist and specialist palliative care.Aim:To describe the models of physician-based palliative care services delivered to patients in the last 12 months of life.Design:This is a population-based retrospective cohort study using linked health care administrative data.Setting/participants:Physicians providing palliative care services to a decedent cohort in Ontario, Canada. The decedent cohort consisted of all adults (18+ years) who died in Ontario, Canada between April 2011 and March 2015 (n = 361,951).Results:We describe four major models of palliative care services: (1) 53.0% of decedents received no physician-based palliative care, (2) 21.2% received only generalist palliative care, (3) 14.7% received consultation palliative care (i.e. care from both specialists and generalists), and (4) 11.1% received only specialist palliative care. Among physicians providing palliative care (n = 11,006), 95.3% had a generalist palliative care focus and 4.7% a specialist focus; 74.2% were trained as family physicians.Conclusion:We examined how often a coordinated palliative care model is delivered to a large decedent cohort and identified that few actually received consultation care. The majority of care, in both the palliative care generalist and specialist models, was delivered by family physicians. Further research should evaluate how different models of care impact patient outcomes and costs.

I n Canada, alcohol use led to an estimated 5.8% of deaths in men and 0.6% of deaths in women in 2017. 1 Alcohol use also imposes a substantial burden on the Canadian health system; between 2014 and 2015, there were 77 000 hospital admissions entirely attributable to alcohol, exceeding the number of admissions for coronary artery disease. 2 A growing body of evidence from the United States, England and Australia has found that alcohol-related mortality and harms, such as hospital admissions or emergency department visits attributable to alcohol use, have increased over the past 2 decades. 3-5 In 2015, rates of hospital admissions attributable to alcohol in Canada were higher in men than in women and older adults. 2 Furthermore, mortality rates specifically attributable to alcohol-related liver disease have been increasing over time in Canada. 1 However, data are lacking on how population-level emergency department visits or hospital admissions attributable to alcohol use in Canada have changed over time and, importantly, whether any changes differ by factors such as age, sex and socioeconomic status. Although alcohol harms appear to be increasing in highincome countries, to our knowledge, only one study set in England has examined contemporary population-level changes in alcohol-related harms by age, sex and income. 4 Emerging data