38 Background: While continuity with one’s primary care physician (PCP) care may be expected to reduce the intensity of end-of-life care, evidence to date has been inconclusive. Methods: Using the Surveillance, Epidemiology, and End Results–Medicare database, we identified 63,269 decedents who were diagnosed with cancer during the years 2004-2011, had at least 4 PCP visits within the year prior to cancer diagnosis, and died within 6-36 months of diagnosis. Care continuity was defined as having at least one outpatient visit within 6 months of cancer diagnosis by the PCP who saw the patient most frequently in the year before cancer diagnosis. Measures of intensive end-of-life care included chemotherapy received within 14 days of death, > 1 emergency department (ED) visit, > 1 hospitalization, ≥ 1 intensive care unit (ICU) admission or no hospice enrollment within 30 days of death. Using hierarchical generalized linear models, we examined the associations between care continuity and end-of-life care patterns, controlling for patient demographics, numbers of outpatient clinic visits prior to cancer diagnosis, clinical factors and survival duration. Results: Approximately 81.3% of our cohort (N = 51,462) had at least 1 visit with their PCP following their cancer diagnosis. Compared with those who did not have at least 1 visit, patients who saw their PCP after their cancer diagnosis were less likely to use hospice within 30 days of death (adjusted odds ratio [AOR] 0.86; 95% confidence interval [CI] 0.82-0.90). They were more likely to have repeated hospitalization (AOR 1.16; 95% CI 1.10-1.24), repeated ED visits (AOR 1.16; 95% CI 1.10-1.24), ICU admission (AOR 1.16; 95% CI 1.10-1.24), and in-hospital death (AOR 1.14; 95% CI 1.08-1.20). They also had higher expenditures within the last month of life. Results were virtually identical whether we further controlled for the Usual Provider Care index (UPC) or the Continuity of Care Index (COCI). Conclusions: Having a follow-up visit with one’s PCP is associated with an increase in end-of-life care intensity. Given potential confounding, the results should be interpreted with caution; however, this study indicates room for PCPs to improve end-of-life care quality for cancer decedents.
Primary Care Physician Supply, Insurance Type, and Late-Stage Cancer Diagnosis
