Increasing involvement of palliative care generalists may improve access to palliative care. It is unknown, however, if their involvement with and without palliative care specialists are associated with different outcomes.
Aim:
To describe physician-based models of palliative care and their association with healthcare utilization outcomes including: emergency department visits, acute hospitalizations and intensive care unit (ICU) admissions in last 30 days of life; and, place of death.
Design:
Population-based retrospective cohort study using linked health administrative data. We used descriptive statistics to compare outcomes across three models (generalist-only palliative care; consultation palliative care, comprising of both generalist and specialist care; and specialist-only palliative care) and conducted a logistic regression for community death.
Setting/participants:
All adults aged 18–105 who died in Ontario, Canada between April 1, 2012 and March 31, 2017.
Results:
Of the 231,047 decedents who received palliative services, 40.3% received generalist, 32.3% consultation and 27.4% specialist palliative care. Across models, we noted minimal to modest variation for decedents with at least one emergency department visit (50%–59%), acute hospitalization (64%–69%) or ICU admission (7%–17%), as well as community death (36%–40%). In our adjusted analysis, receipt of a physician home visit was a stronger predictor for increased likelihood of community death (odds ratio 9.6, 95% confidence interval 9.4–9.8) than palliative care model (generalist vs consultation palliative care 2.0, 1.9–2.0).
Conclusion:
The generalist palliative care model achieved similar healthcare utilization outcomes as consultation and specialist models. Including a physician home visit component in each model may promote community death.
QuillTEAbernethyAP.Generalist plus specialist palliative care - creating a more sustainable model. N Engl J Med2013; 368(13): 1173–1175.
2.
BrownCRLHsuATKendallC, et al. How are physicians delivering palliative care? A population-based retrospective cohort study describing the mix of generalist and specialist palliative care models in the last year of life. Palliat Med2018; 32(8): 1334–1343.
HigginsonIJEvansCJ.What is the evidence that palliative care teams improve outcomes for cancer patients and their families?Cancer J2010; 16(5): 423–435.
5.
LuckettTPhillipsJAgarM, et al. Elements of effective palliative care models: a rapid review. BMC Health Serv Res2014; 14: 136.
6.
SioutaNVan BeekKVan Der EerdenME, et al. Integrated palliative care in Europe: a qualitative systematic literature review of empirically-tested models in cancer and chronic disease. BMC Palliat Care2016; 15: 56.
7.
ErnecoffNCCheckDBannonM, et al. Comparing specialty and primary palliative care interventions: analysis of a systematic review. J Palliat Med2020; 23(3): 389–396.
8.
GardinerCGottMIngletonC.Factors supporting good partnership working between generalist and specialist palliative care services: a systematic review. Br J Gen Pract2012; 62(598): e353–e362.
9.
HillADStukelTAFuL, et al. Trends in site of death and health care utilization at the end of life: a population-based cohort study. CMAJ Open2019; 7(2): E306–E315.
10.
BekelmanJEHalpernSDBlankartCR, et al. Comparison of site of death, health care utilization, and hospital expenditures for patients dying with cancer in 7 developed countries. JAMA2016; 315(3): 272–283.
11.
QureshiDTanuseputroPPerezR, et al. Place of care trajectories in the last two weeks of life: a population-based cohort study of Ontario decedents. J Palliat Med2018; 21(11): 1588–1595.
12.
BarberaLPaszatLQiuF.End-of-life care in lung cancer patients in Ontario: aggressiveness of care in the population and a description of hospital admissions. J Pain Symptom Manage2008; 35(3): 267–274.
13.
TanuseputroPBudhwaniSBaiYQ, et al. Palliative care delivery across health sectors: a population-level observational study. Palliat Med2017; 31(3): 247–257.
14.
SeowHBrazilKSussmanJ, et al. Impact of community based, specialist palliative care teams on hospitalisations and emergency department visits late in life and hospital deaths: a pooled analysis. BMJ2014; 348(June): g3496.
15.
TanuseputroPBeachSChalifouxM, et al. Associations between physician home visits for the dying and place of death: a population-based retrospective cohort study. PLoS One2018; 13(2): 1–14.
16.
BreretonLClarkJIngletonC, et al. What do we know about different models of providing palliative care? Findings from a systematic review of reviews. Palliat Med2017; 31: 781–797.
PilkeyJDownarJDudgeonD, et al. Palliative medicine—becoming a subspecialty of the royal college of physicians and surgeons of Canada. J Palliat Care2017; 32(3–4): 113–120.
22.
BarberaLHweeJKlingerC, et al. Identification of the physician workforce providing palliative care in Ontario using administrative claims data. CMAJ Open2015; 3(3): E292–E298.
23.
ThavornKMaxwellCJGruneirA, et al. Effect of socio-demographic factors on the association between multimorbidity and healthcare costs: a population-based, retrospective cohort study. BMJ Open2017; 7(10): e017264.
24.
JaakkimainenRLBronskillSETierneyMC, et al. Identification of physician-diagnosed Alzheimer’s disease and related dementias in population-based administrative data: a validation study using family physicians’ electronic medical records. J Alzheimers Dis2016; 54(1): 337–349.
25.
MondorLCohenDKhanAI, et al. Income inequalities in multimorbidity prevalence in Ontario, Canada: a decomposition analysis of linked survey and health administrative data. Int J Equity Health2018; 17(1): 90.
26.
MondorLMaxwellCJHoganDB, et al. Multimorbidity and healthcare utilization among home care clients with dementia in Ontario, Canada: a retrospective analysis of a population-based cohort. PLoS Med2017; 14(3): e1002249.
27.
GruneirABronskillSEMaxwellCJ, et al. The association between multimorbidity and hospitalization is modified by individual demographics and physician continuity of care: a retrospective cohort study. BMC Health Serv Res2016; 16(1): 154.
28.
MuggahEGravesEBennettC, et al. The impact of multiple chronic diseases on ambulatory care use; a population based study in Ontario, Canada. BMC Health Serv Res2012; 12(1): 452.
29.
Koné PefoyoAJBronskillSEGruneirA, et al. The increasing burden and complexity of multimorbidity. BMC Public Health2015; 15(1): 415.
30.
PetrosyanYBaiYQKoné PefoyoAJ, et al. The relationship between diabetes care quality and diabetes-related hospitalizations and the modifying role of comorbidity. Can J Diabetes2017; 41(1): 17–25.
31.
MondorLMaxwellCJBronskillSE, et al. The relative impact of chronic conditions and multimorbidity on health-related quality of life in Ontario long-stay home care clients. Qual Life Res2016; 25(10): 2619–2632.
32.
LaneNEMaxwellCJGruneirA, et al. Absence of a socioeconomic gradient in older adults’ survival with multiple chronic conditions. EBioMedicine2015; 2(12): 2094–2100.
33.
WoodmanCBaillieJSivellS.The preferences and perspectives of family caregivers towards place of care for their relatives at the end-of-life. A systematic review and thematic synthesis of the qualitative evidence. BMJ Support Palliat Care2016; 6(4): 418–429.
34.
GomesBCalanzaniNGyselsM, et al. Heterogeneity and changes in preferences for dying at home: a systematic review. BMC Palliat Care2013; 12(1): 7.
35.
KimuraTImanagaTMatsuzakiM, et al. Home death is associated with frequency of physician home medical care visits: a questionnaire survey on communications in home medical care settings. Geriatr Gerontol Int2015; 15(4): 465–471.
36.
NeergaardMAVedstedPOlesenF, et al. Associations between home death and GP involvement in palliative cancer care. Br J Gen Pract2009; 59(566): 671–677.
37.
AabomBKragstrupJVondelingH, et al. Does persistent involvement by the GP improve palliative care at home for end-stage cancer patients?Palliat Med2006; 20(5): 507–512.
38.
AliMCapelMJonesG, et al. The importance of identifying preferred place of death. BMJ Support Palliat Care2019; 9: 84–91.
39.
QureshiDTanuseputroPPerezR, et al. Early initiation of palliative care is associated with reduced late-life acute-hospital use: a population-based retrospective cohort study. Palliat Med2019; 33(2): 150–159.
40.
ChengWWWilleyJPalmerJL, et al. Interval between palliative care referral and death among patients treated at a comprehensive cancer center. J Palliat Med2005; 8: 1025–1032.
41.
RosenwaxLSpilsburyKMcNamaraBA, et al. A retrospective population based cohort study of access to specialist palliative care in the last year of life: who is still missing out a decade on?BMC Palliat Care2016; 15(1): 46.
42.
BennettMIZieglerLAllsopM, et al. What determines duration of palliative care before death for patients with advanced disease? A retrospective cohort study of community and hospital palliative care provision in a large UK city. BMJ Open2016; 6(12): e012576.
43.
JanahAGauthierLRMorinL, et al. Access to palliative care for cancer patients between diagnosis and death: a national cohort study. Clin Epidemiol2019; 11: 443–455.
44.
BoneAEGomesBEtkindSN, et al. What is the impact of population ageing on the future provision of end-of-life care? Population-based projections of place of death. Palliat Med2018; 32(2): 329–336.
45.
MathersCDLoncarD.Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med2006; 3(11): 2011–2030.
46.
LupuDQuigleyLMehfoudN, et al. The growing demand for hospice and palliative medicine physicians: will the supply keep up?J Pain Symptom Manage2018; 55(4): 1216–1223.
47.
CentenoCLynchTGarraldaE, et al. Coverage and development of specialist palliative care services across the World Health Organization European region (2005–2012): results from a European Association for Palliative Care Task Force survey of 53 countries. Palliat Med2016; 30(4): 351–362.
48.
MarshallDHowellDBrazilK, et al. Enhancing family physician capacity to deliver quality palliative home care: an end-of-life, shared-care model. Can Fam Physician2008; 54: 1703.
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