Provider Continuity Prior to the Diagnosis of Advanced Lung Cancer and End-of-Life Care

PLOS ONE, Dec 2019

Background Little is known about the effect of provider continuity prior to the diagnosis of advanced lung cancer and end-of-life care. Methods Retrospective analysis of 69,247 Medicare beneficiaries aged 67 years or older diagnosed with Stage IIIB or IV lung cancer between January 1, 1993 and December 31, 2005 who died within two years of diagnosis. We examined visit patterns to a primary care physician (PCP) and/or any provider one year prior to the diagnosis of advanced lung cancer as measures of continuity of care. Outcome measures were hospitalization, ICU use and chemotherapy use during the last month of life, and hospice use during the last week of life. Results Seeing a PCP or any provider in the year prior to the diagnosis of advanced lung cancer increased the likelihood of hospitalization, ICU care, chemotherapy and hospice use during the end of life. Patients with 1–3, 4–7 or >7 visits to their PCP in the year prior to the diagnosis of lung cancer had 1.0 (reference), 1.08 (95% CI; 1.04–1.13), and 1.14 (95% CI; 1.08–1.19) odds of hospitalization during the last month of life, respectively. Odds of hospice use during the last week of life were higher in patients with visits to multiple PCPs (OR 1.10: 95% CI; 1.06–1.15) compared to those whose visits were all to the same PCP. Conclusion Provider continuity in the year prior to the diagnosis of advanced lung cancer was not associated with lower use of aggressive care during end of life. Our study did not have information on patient preferences and result should be interpreted accordingly.

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Provider Continuity Prior to the Diagnosis of Advanced Lung Cancer and End-of-Life Care

Goodwin JS (2013) Provider Continuity Prior to the Diagnosis of Advanced Lung Cancer and End-of-Life Care. PLoS ONE 8(9): e74690. doi:10.1371/journal.pone.0074690 Provider Continuity Prior to the Diagnosis of Advanced Lung Cancer and End-of-Life Care Gulshan Sharma 0 Yue Wang 0 James E. Graham 0 Yong-Fang Kuo 0 James S. Goodwin 0 William C. S. Cho, Queen Elizabeth Hospital, Hong Kong 0 1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Texas Medical Branch , Galveston, Texas , United States of America, 2 Department of Internal Medicine, University of Texas Medical Branch , Galveston, Texas , United States of America, 3 Department of Rehabilitation Sciences, University of Texas Medical Branch , Galveston, Texas , United States of America, 4 Department of PMCH Epidemiology and Biostatistics, University of Texas Medical Branch , Galveston, Texas , United States of America, 5 Department of Internal Medicine, Sealy Center of Aging, University of Texas Medical Branch , Galveston, Texas , United States of America Background: Little is known about the effect of provider continuity prior to the diagnosis of advanced lung cancer and endof-life care. Methods: Retrospective analysis of 69,247 Medicare beneficiaries aged 67 years or older diagnosed with Stage IIIB or IV lung cancer between January 1, 1993 and December 31, 2005 who died within two years of diagnosis. We examined visit patterns to a primary care physician (PCP) and/or any provider one year prior to the diagnosis of advanced lung cancer as measures of continuity of care. Outcome measures were hospitalization, ICU use and chemotherapy use during the last month of life, and hospice use during the last week of life. Results: Seeing a PCP or any provider in the year prior to the diagnosis of advanced lung cancer increased the likelihood of hospitalization, ICU care, chemotherapy and hospice use during the end of life. Patients with 1-3, 4-7 or .7 visits to their PCP in the year prior to the diagnosis of lung cancer had 1.0 (reference), 1.08 (95% CI; 1.04-1.13), and 1.14 (95% CI; 1.081.19) odds of hospitalization during the last month of life, respectively. Odds of hospice use during the last week of life were higher in patients with visits to multiple PCPs (OR 1.10: 95% CI; 1.06-1.15) compared to those whose visits were all to the same PCP. Conclusion: Provider continuity in the year prior to the diagnosis of advanced lung cancer was not associated with lower use of aggressive care during end of life. Our study did not have information on patient preferences and result should be interpreted accordingly. - Funding: This work was supported by grant K-08 AG 031583, K05-CA134923, and R01-AG033134 from the National Institutes of Health and RP101207 from the Cancer Prevention and Research Institute of Texas. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. Outpatient provider continuity is central to the medical home concept of the Patient Protection and Affordable Care Act and is key to good medical care[1]. It is associated with improved patient satisfaction,[2] increased use of appropriate preventive health services[37], greater medication compliance, lower hospitalization rates,[812] less emergency department use[13] and fewer duplicate tests.[14] Moreover, continuity of care with a primary care physician (PCP) has shown substantial reductions in mortality among older adults.[15] Continuity is beneficial for cancer patients both prior to and after diagnosis. Pre-diagnosis continuity leads to diagnoses at earlier stages.[16] PCP continuity after cancer diagnosis increases the likelihood of receiving guideline concordant therapy,[17] decreases the likelihood of emergency room visits in the last six months of life,[18] and increases the likelihood of dying at home.[19] Patients visited by their PCP during their last hospitalization (outpatient to inpatient provider continuity) are less likely to receive Intensive Care Unit (ICU) care.[20] Studies of the effects of continuity on end-of-life care in cancer patients are primarily limited to patients already diagnosed with cancer. We were interested in whether the continuity established prior to this life- and care-altering event (diagnosis of advanced lung cancer) has enduring effects on the end-of-life medical care these patients received. Our hypothesis was that provider continuity prior to the diagnosis of advanced cancer is associated with lower hospitalization, less ICU use, less chemotherapy use and higher hospice use at the end of life. These measures are considered indicators of potentially appropriate care. We used a national sample of newly-diagnosed advanced lung cancer patients to examine the effect of provider continuity prior to the diagnosis of advanced lung cancer on end-of-life medical ca (...truncated)


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Gulshan Sharma, Yue Wang, James E. Graham, Yong-Fang Kuo, James S. Goodwin. Provider Continuity Prior to the Diagnosis of Advanced Lung Cancer and End-of-Life Care, PLOS ONE, 2013, Volume 8, Issue 9, DOI: 10.1371/journal.pone.0074690