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Greater PCP involvement in end-of-life planning may lead to lower Medicare spending, less intensive patient care

If primary care physicians become more involved in the management of chronically ill patients near the end of their lives, it could lower Medicare costs by almost $4,000 per patient, according to recently published research in Annals of Family Medicine.

Researchers also reported that the involvement could translate to patients spending less time in hospices and intensive care units.

“These findings add evidence to our increasing understanding that physician and health system characteristics often drive variation in end-of-life care. We found notable variation in the involvement of primary care physicians vs. specialists in the last months of life,” Claire K. Ankuda, MD, MPH, of the Robert Wood Johnson Foundation Clinical Scholars Program at the University of Michigan Health System, Ann Arbor, and colleagues wrote.

“This study fills in gaps by demonstrating that primary care physicians are the main physicians for about half of the [hospital referral regions (HRRs)] in the country, and regions where they are the predominant clinician in the last 6 months of life have less costly and intensive end-of-life care.

Researchers studied 2010 HRR data from the Dartmouth Atlas for their study, using a cohort of patients who had at least one of the following conditions: coronary artery disease, severe chronic liver disease, chronic renal failure, peripheral vascular disease, diabetes with end organ damage, dementia, chronic pulmonary disease, congestive heart failure and cancer/leukemia.

According to researchers, the primary independent variable was the proportion of primary care visits to specialist visits in the patients’ last 6 months of life, as determined by Medicare claims data of visits during that same time period. Primary outcome measures were Medicare spending, ICU days in the final 6 months of life, percentage of patients receiving ICU care during their final hospital admission, percentage of patients seeing 10 or more physicians during the final 6 months of life, aggregate hospice enrollment rates, and the percentage of deaths taking place in the hospital.

Researchers analyzed data from 1,107,702 Medicare Part B beneficiaries with chronic disease who had died. The interquartile range of the HRR ratio ofprimary care to specialist end-of-life visits was 0.77 to 1.21 When the data were adjusted for differences in health systems, population and patient characteristics, HRRs with the greatest primary care physician involvement had less hospice enrollment (44.5% of decedents vs. 50.4%; P = .004), fewer intensive care unit days in the last 6 months of life (2.9 vs. 4.29; P < .001), and lower Medicare spending in the last 2 years of life ($65,160 vs. $69,030; P = .003).

“This study provides preliminary evidence that the involvement of primary care physicians is a source of regional variation in end-of-life care. In addition, it is promising that areas of high primary care physician involvement appear to have lower-intensity, lower-cost care,” Ankuda and colleagues wrote. “Given the size of the aging population and the magnitude of the primary care physician infrastructure, further work to understand and optimize the role of primary care physicians will be critical to improve care of the dying.” – by Janel Miller

Disclosure: The researchers report no relevant financial disclosures.