title: Can primary care visits reduce hospital utilization among Medicare beneficiaries at the end of life?
abstract: BACKGROUND
  Medical care at the end of life is often expensive and ineffective.
  
  
  OBJECTIVE
  To explore associations between primary care and hospital utilization at the end of life.
  
  
  METHODS
  Retrospective analysis of Medicare data. We measured hospital utilization during the final 6 months of life and the number of primary care physician visits in the 12 preceding months. Multivariate cluster analysis adjusted for the effects of demographics, comorbidities, and geography in end-of-life healthcare utilization.
  
  
  METHODS
  National random sample of 78,356 Medicare beneficiaries aged 66+ who died in 2001. Non-whites were over-sampled. All subjects with complete Medicare data for 18 months prior to death were retained, except for those in the End Stage Renal Disease program.
  
  
  METHODS
  Hospital days, costs, in-hospital death, and presence of two types of preventable hospital admissions (Ambulatory Care Sensitive Conditions) during the final 6 months of life.
  
  
  RESULTS
  Sample characteristics: 38% had 0 primary care visits; 22%, 1-2; 19%, 3-5; 10%, 6-8; and 11%, 9+ visits. More primary care visits in the preceding year were associated with fewer hospital days at end of life (15.3 days for those with no primary care visits vs. 13.4 for those with > or = 9 visits, P < 0.001), lower costs ($24,400 vs. $23,400, P < 0.05), less in-hospital death (44% vs. 40%, P < 0.01), and fewer preventable hospitalizations for those with congestive heart failure (adjusted odds ratio, aOR = 0.82, P < 0.001) and chronic obstructive pulmonary disease (aOR = 0.81, P = 0.02).
  
  
  CONCLUSIONS
  Primary care visits in the preceding year are associated with less, and less costly, end-of-life hospital utilization. Increased primary care access for Medicare beneficiaries may decrease costs and improve quality at the end of life.
authors.affiliation: Section of General Internal Medicine, Evans Department of Medicine, Boston University Medical Center, Boston, MA 02118, USA. Andrea.Kronman@bmc.org
authors.forename: Andrea C
authors.initials: AC
authors.lastname: Kronman
authors.forename: Arlene S
authors.initials: AS
authors.lastname: Ash
authors.forename: Karen M
authors.initials: KM
authors.lastname: Freund
authors.forename: Amresh
authors.initials: A
authors.lastname: Hanchate
authors.forename: Ezekiel J
authors.initials: EJ
authors.lastname: Emanuel
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003266:Continuity of Patient Care / Q000191:economics*; D003365:Costs and Cost Analysis; D003430:Cross-Sectional Studies; D005260:Female; D006760:Hospitalization / Q000191:economics*; D006801:Humans; D008297:Male; D006278:Medicare; D011320:Primary Health Care / Q000191:economics*; D013727:Terminal Care / Q000191:economics*; D014481:United States