Variation in End-of-life Care

Patients tend to get more expensive in the last year of their life, often because the cause of death involves a severe episode of an ongoing chronic condition, like a stroke from high blood pressure or heart attack stemming from ischemic heart disease.  So efforts have been made to understand and moderate this spending.  A new piece of research in the Annals of Internal Medicine examines whether the involvement of primary care physicians in end-of-life care can lead to lower spending.  (Annals Article)   The researchers used Medicare data from 2010 to assess the ratio primary care to specialist visits in the last six months of life, at a hospital referral region level, and to ascertain any link between that ratio and resource use in other categories, such as hospitalizations.

There is significant regional variation in end-of-life spending, some of which has been linked to provider factors.  In general, Medicare spending may be lower where there is a higher ratio of primary care doctors for the beneficiary population.  The researchers in this study divided the HRRs into quartiles based on the primary care to specialist visit ratio.  The range of ratios was .77 primary care visits to specialist visits to 1.21.  The regions with the highest ratios tended to have less minorities, patients with a lower burden of illness and to be more rural.  These regions also had less use of hospice near end-of-life and less use of ICU days, but there was no difference in overall hospital days or number of deaths in a hospital.  There was slightly less overall Medicare spending in the last two years of life in the primary care intense regions and somewhat less fragmented care, as measured by number of doctors seen by a patient.  So more primary care involvement appears to be tied to less intensive resource use, but little difference in site of death.  It would be very interesting to extend the research by examining whatever data exists on patients or caregiver satisfaction with the end-of-life care.