title: Regional Variation in Primary Care Involvement at the End of Life.
abstract: Variation in end-of-life care in the United States is frequently driven by the health care system. We assessed the association of primary care physician involvement at the end of life with end-of-life care patterns.
  
  
  
  We analyzed 2010 Medicare Part B claims data for US hospital referral regions (HRRs). The independent variable was the ratio of primary care physicians to specialist visits in the last 6 months of life. Dependent variables included the rate of hospital deaths, hospital and intensive care use in the last 6 months of life, percentage of patients seen by more than 10 physicians, and Medicare spending in the last 2 years of life. Robust linear regression analysis was used to measure the association of primary care physician involvement at the end of life with the outcome variables, adjusting for regional characteristics.
  
  
  
  We assessed 306 HRRs, capturing 1,107,702 Medicare Part B beneficiaries with chronic disease who died. The interquartile range of the HRR ratio of primary care to specialist end-of-life visits was 0.77 to 1.21. HRRs with high vs low primary care physician involvement at the end of life had significantly different patient, population, and health system characteristics. Adjusting for these differences, HRRs with the greatest primary care physician involvement had lower Medicare spending in the last 2 years of life ($65,160 vs $69,030;P= .003) and fewer intensive care unit days in the last 6 months of life (2.90 vs 4.29;P<.001), but also less hospice enrollment (44.5% of decedents vs 50.4%;P= .004).
  
  
  
  Regions with greater primary care physician involvement in end-of-life care have overall less intensive end-of-life care.
authors.affiliation: Robert Wood Johnson Clinical Scholars Program, Family Medicine, University of Michigan Health System, Ann Arbor, Michigan cankuda@umich.edu.
authors.forename: Claire K
authors.initials: CK
authors.lastname: Ankuda
authors.affiliation: Robert Graham Center, Washington, DC.
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Petterson
authors.affiliation: Robert Graham Center, Washington, DC.
authors.forename: Peter
authors.initials: P
authors.lastname: Wingrove
authors.affiliation: Robert Graham Center, Washington, DC.
authors.forename: Andrew W
authors.initials: AW
authors.lastname: Bazemore
mesh_terms: D000368:Aged; D003710:Demography; D005260:Female; D005843:Geography; D006801:Humans; D007345:Insurance Claim Review; D016014:Linear Models; D008297:Male; D016345:Medicare Part B / Q000706:statistics & numerical data*; D058007:Physicians, Primary Care; D011320:Primary Health Care / Q000191:economics*; D012017:Referral and Consultation; D013727:Terminal Care / Q000706:statistics & numerical data*; D014481:United States
keywords: death; end-of-life care; family practice; healthcare services research; hospice; internal medicine; palliative care; primary care