Regional Variation in Primary Care Involvement at the End of Life

Ankuda, Claire K.; Petterson, Stephen; Wingrove, Peter; Bazemore, Andrew

doi:10.1370/afm.2002

Cited by 23 publications

(14 citation statements)

References 28 publications

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“…Contrary to the typical focus of palliative care towards terminal cancer diagnoses, our study reveals the application of a palliative approach to care for patients with several other chronic, progressive life-limiting illnesses. The duration of non-cancer palliative needs can be longer and less certain than that for cancer [33,37] and the needs of patients with non-cancer life-limiting illnesses can be less intense over this prolonged period, making early identi cation a challenge. This could be one reason that only 25% of patients received a PAC in their last year of life, as most deaths were non-cancer related.…”

Section: Discussionmentioning

confidence: 99%

“…We conducted a cross-sectional study to determine, by chart review, how consistently one FHT was implementing elements of PAC with patients in their last year of life. We chose the last year of life to align with literature showing sharp increases in levels of disability in the last year of life, [33] the frequent reference to the last year of life in recommendations to initiate palliative care, [34] and recognizing that a palliative approach to care should be incorporated from the time of diagnosis of a progressive lifelimiting illness. [11] The study was conducted in an FHT made up of two multi-physician family medicine clinics in one city, serving approximately 40,000 patients.…”

Section: Methodsmentioning

confidence: 99%

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Description of a Palliative Approach to Care to Patients in the Last Year of Life in a Primary Care Setting

Gallagher

Carter-Ramirez

Boese

et al. 2020

Preprint

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Background: Most patients nearing the end of life can benefit from a palliative approach in primary care. We currently do not know how to measure a palliative approach in family practice. The objective of this study was to describe the provision of a palliative approach and evaluate their clinicians’ perceptions of the results.Methods: We conducted a descriptive study of deceased patients in an interprofessional team family practice. We integrated conceptual models of a palliative approach to create a chart review tool to capture a palliative approach in the last year of life and assessed a global rating of whether a palliative approach was provided. Clinicians completed a questionnaire before learning the results and after, on perceptions of how often they believed a palliative approach was provided by the team.Results: Among 79 patients (mean age at death 73 years, 54% female) cancer and cardiac diseases were the top conditions responsible for death. One-quarter of patients were assessed as having received a palliative approach. 53% of decedents had a documented discussion about goals of care, 41% had nurse involvement, and 15.2% had a discussion about caregiver well-being. These indicators had the greatest discrimination between a palliative approach or not. Agreement that elements of a palliative approach were provided decreased significantly on the clinician questionnaire from before to after viewing the results. Conclusions: This study identified measurable indicators of a palliative approach in family practice, that can be used as the basis for quality improvement.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Description of a Palliative Approach to Care to Patients in the Last Year of Life in a Primary Care Setting

Gallagher

Carter-Ramirez

Boese

et al. 2020

Preprint

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“…However, ACOs could seek to improve care for their older patients with serious illness, and such efforts could affect the outcome measures in our study. Furthermore, PCPs may have key roles in communicating and clarifying information at the EoL including setting care priorities and assisting patients’ treatment decisions . Currently, Medicare ACO quality metrics do not include any measures specific to EoL care; inclusion of such measures might increase ACOs’ attention to improving EoL care for cancer patients.…”

Section: Discussionmentioning

confidence: 99%

Aggressive Care near the End of Life for Cancer Patients in Medicare Accountable Care Organizations

Kim

Keating

Perloff

et al. 2019

J American Geriatrics Society

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OBJECTIVES To compare aggressiveness of end‐of‐life (EoL) care for older cancer patients attributed to Medicare Shared Savings Programs with that for similar fee for service (FFS) beneficiaries not in an accountable care organization (ACO) and examine whether observed differences in EoL care utilization vary across markets that differ in ACO penetration. DESIGN Cross‐sectional observational study comparing ACO‐attributed beneficiaries with propensity score–matched beneficiaries not attributed to an ACO. SETTING A total of 21 hospital referral regions (HRRs) in the United States. PARTICIPANTS Medicare FFS beneficiaries with a cancer diagnosis who were 66 years or older and died in 2013‐2014. MEASUREMENTS Outcome measures were claims‐based quality measures of aggressive EoL care: (1) one or more intensive care unit (ICU) admissions in the last month of life, (2) two or more hospitalizations in the last month of life, (3) two or more emergency department visits in the last month of life, (4) chemotherapy 2 weeks or less before death, and (5) no hospice enrollment or hospice enrollment within 3 days of death. Analyses were adjusted for demographic and clinical characteristics of beneficiaries and practice characteristics. RESULTS Compared with beneficiaries not in an ACO, ACO‐attributed beneficiaries had a higher rate of ICU admission during the last month of life (37.7% vs 34.0%; adjusted difference = +2.8 percentage points; 95% confidence interval (CI) = 1.0‐4.6) but fewer repeated hospitalizations (14.5% vs 15.2%; adjusted difference = −1.7 percentage points; CI = −3.1 to −.3). Other measures did not differ for the two groups. Although the ICU admission rates tended to decrease as ACO‐penetration rates increased (P < .01), ACO patients had higher rates of ICU admission than non‐ACO patients in both medium and high ACO‐penetration HRRs. CONCLUSION Cancer patients attributed to ACOs had fewer repeated hospitalizations but more ICU admissions in the last month of life than non‐ACO patients; they had similar rates of other measures of aggressive care at the EoL. This suggests opportunities for ACOs to improve EoL care for cancer patients. J Am Geriatr Soc 67:961–968, 2019.

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“…Moreover, a more detailed analysis of the association between treatment intensity and the density of different types of specialists and primary care physicians in the ambulatory setting might be useful in explaining the regional differences in the treatment patterns of cancer patients. 47 , 48 …”

Section: Discussionmentioning

confidence: 99%

Intensity of treatment in Swiss cancer patients at the end-of-life

Bähler¹,

Signorell²,

Blozik³

et al. 2018

CMAR

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PurposeCurrent evidence on the care-delivering process and the intensity of treatment at the end-of-life of cancer patients is limited and remains unclear. Our objective was to examine the care-delivering processes in health care during the last months of life with real-life data of Swiss cancer patients.Patients and methodsThe study population consisted of adult decedents in 2014 who were insured at Helsana Group. Data on the final cause of death were provided additionally by the Swiss Federal Statistical Office. Of the 10,275 decedents, 2,710 (26.4%) died of cancer. Intensity of treatment and health care utilization (including transitions) at their end-of-life were examined. Intensity measures included the following: last dose of chemotherapy within 14 days of death, a new chemotherapy regimen starting <30 days before death, more than one hospital admission or spending >14 days in hospital in the last month, death in an acute care hospital, more than one emergency visit and ≥1 intensive care unit admission in the last month of life.ResultsIn the last 6 months of life, 89.5% of cancer patients had ≥1 transition, with 87.2% being hospitalized. Within 30 days before death, 64.2% of the decedents had ≥1 intensive treatment, whereby 8.9% started a new chemotherapy. In the multinomial logistic regression model, older age, higher density of nursing home beds and home care nurses were associated with a decrease, while living in the Italian- or French-speaking part of Switzerland was associated with an increase in intensive care.ConclusionSwiss cancer patients insured by Helsana Group experience a considerable number of transitions and intensive treatments at the end-of-life, whereby treatment intensity declines with increasing age. Among others, increased home care nursing might be helpful to reduce unwarranted treatments and transitions, therefore leading to better care at the end-of-life.

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Regional Variation in Primary Care Involvement at the End of Life

Cited by 23 publications

References 28 publications

Description of a Palliative Approach to Care to Patients in the Last Year of Life in a Primary Care Setting

Description of a Palliative Approach to Care to Patients in the Last Year of Life in a Primary Care Setting

Aggressive Care near the End of Life for Cancer Patients in Medicare Accountable Care Organizations

Intensity of treatment in Swiss cancer patients at the end-of-life

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