Primary care service use by end-of-life cancer patients: a nationwide population-based cohort study in the United Kingdom

Abstract

Background: End of life (EoL) care becomes more complex and increasingly takes place in the community, but there is little data on the use of general practice (GP) services to guide care improvement. This study aims to determine the trends and factors associated with GP consultation, prescribing and referral to other care services amongst cancer patients in the last year of life. Methods: A retrospective cohort study of cancer patients who died in 2000-2014, based on routinely collected primary care data (the Clinical Practice Research DataLink, CPRD) covering a representative sample of the population in the United Kingdom. Outcome variables were number of GP consultations (primary), number of prescriptions and referral to other care services (yes vs no) in the last year of life. Explanatory variables included socio-demographics, clinical characteristics and the status of palliative care needs recognised or not. The association between outcome and explanatory variables were evaluated using multiple-adjusted risk ratio (aRR). Results: Of 68,523 terminal cancer patients, 70% were aged 70+, 75% had comorbidities and 45.5% had palliative care needs recognised. In the last year of life, a typical cancer patient had 43 GP consultations (Standard deviation (SD): 31.7; total = 3,031,734), 71.5 prescriptions (SD: 68.0; total = 5,074,178), and 21(SD: 13.0) different drugs; 58.0% of patients had at least one referral covering all main clinical specialities. More comorbid conditions, prostate cancer and having palliative care needs recognised were associated with more primary care consultations, more prescriptions and a higher chance of referral (aRRs 1.07-2.03). Increasing age was related to fewer consultations (aRRs 0.77-0.96), less prescriptions (aRR 1.09-1.44), and a higher chance of referral (aRRs 1.08-1.16) but less likely to have palliative care needs recognised (aRRs 0.53-0.89).

Healthcare trajectories and costs in the last year of life: a retrospective primary care and hospital analysis

“…CPRD is an ongoing research service providing electronic medical record data across GP practices in the UK, covering approximately 7% of the population. [17][18][19] HES provides data on secondary care use in England, including hospitalisations, Accident & Emergency (A&E) contacts, intensive care unit (ICU) use and outpatient care. This was supplemented with data from the English Index of Multiple Deprivation (IMD) at the level of the lower super output area of the patient's residence.…”

Palliative Care: A Primary Care Pharmacist Perspective

“…In agreement with the Gold Standard Framework guidance, patients in the UK are added onto the GPs palliative register when they are believed to be in their last 12 months of life [ 6 ]. These patients have acknowledged needs at the different stages of their palliative journey [ 7 , 8 ]. For instance, an average cancer patient may contact their GP at least 43 times in their last year of life.…”

“…During these consults, an average of 72 prescriptions are issued, 21 of which are new drugs. In general, having palliative care needs recognised is ultimately associated with an increased number of GP contacts [ 7 ].…”

“…Access to the full medical history and the ability to liaise with all stakeholders allow for establishing the much-desired continuity within the emerging primary-care-access models: pharmacists may act as point of contact for all medication-related concerns. This role is even more significant considering that a growing majority of palliative care patients are cared for in their homes [ 1 , 2 , 3 , 4 , 5 , 7 , 9 , 10 , 11 ].…”

“…This example demonstrates the importance of appreciating the patients’ perspectives on handling their medications. On the other hand, medication management and the medicine information needs of palliative patients and their carers are so often undermined and underappreciated by their clinical teams [ 3 , 4 , 5 , 7 , 9 , 10 , 11 ]. Latif et al emphasise the lack of awareness of the stress and emotional burden of administering potent medicines in the domiciliary setting [ 9 ].…”