title: Health care restructuring and family physician care for those who died of cancer.
abstract: BACKGROUND
  During the 1990s, health care restructuring in Nova Scotia resulted in downsized hospitals, reduced inpatient length of stay, capped physician incomes and restricted practice locations. Concurrently, the provincial homecare program was redeveloped and out-of-hospital cancer deaths increased from 20% (1992) to 30% (1998). These factors all pointed to a transfer of end-of-life inpatient hospital care to more community-based care. The purpose of this study was to describe the trends in the provision of Family Physician (FP) visits to advanced cancer patients in Nova Scotia (NS) during the years of health care restructuring.
  
  
  METHODS
  Design Secondary multivariate analysis of linked population-based datafiles including the Queen Elizabeth II Health Sciences Centre Oncology Patient Information System (NS Cancer Registry, Vital Statistics), the NS Hospital Admissions/Separations file and the Medical Services Insurance Physician Services database. Setting Nova Scotia, an eastern Canadian province (population: 950,000).
  
  
  METHODS
  All patients who died of lung, colorectal, breast or prostate cancer between April 1992 and March 1998 (N = 7,212). Outcome Measures Inpatient and ambulatory FP visits, ambulatory visits by location (office, home, long-term care facility, emergency department), time of day (regular hours, after hours), total length of inpatient hospital stay and number of hospital admissions during the last six months of life.
  
  
  RESULTS
  In total, 139,641 visits were provided by family physicians: 15% of visits in the office, 10% in the home, 5% in the emergency department (ED), 5% in a long-term-care centre and 64% to hospital inpatients. There was no change in the rate of FP visits received for office, home and long-term care despite the fact that there were 13% fewer hospital admissions, and length of hospital stay declined by 21%. Age-sex adjusted estimates using negative binomial regression indicate a decline in hospital inpatient FP visits over time compared to 1992-93 levels (for 1997-98, adjusted RR = 0.88, 95%CI = 0.81-0.95) and an increase in FP ED visits (for 1997-98, adjusted RR = 1.18, 95%CI = 1.05-1.34).
  
  
  CONCLUSIONS
  Despite hospital downsizing and fewer deaths occurring in hospitals, FP ambulatory visits (except for ED visits) did not rise correspondingly. Although such restructuring resulted in more people dying out of hospital, it does not appear FPs responded by providing more medical care to them in the community.
authors.affiliation: Department of Family Medicine, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada. fred.burge@dal.ca
authors.forename: Frederick I
authors.initials: FI
authors.lastname: Burge
authors.forename: Beverley
authors.initials: B
authors.lastname: Lawson
authors.forename: Grace
authors.initials: G
authors.lastname: Johnston
authors.forename: Gordon
authors.initials: G
authors.lastname: Flowerdew
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000401:mortality; D015179:Colorectal Neoplasms / Q000401:mortality; D003153:Community Health Services / Q000600:supply & distribution*; D005194:Family Practice / Q000706:statistics & numerical data*; D005260:Female; D006754:Hospital Restructuring; D006760:Hospitalization / Q000706:statistics & numerical data*; D006792:House Calls / Q000706:statistics & numerical data*; D006801:Humans; D008175:Lung Neoplasms / Q000401:mortality; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009369:Neoplasms / Q000401:mortality* / Q000628:therapy*; D009674:Nova Scotia / Q000453:epidemiology; D009819:Office Visits / Q000706:statistics & numerical data*; D011471:Prostatic Neoplasms / Q000401:mortality; D013727:Terminal Care / Q000706:statistics & numerical data*