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Author List:
Lorenz KA (VA GLAHS)
Asch SM (VA GLAHS)
Rubenstein LR (VA GLAHS)
Lynn J (Washington Home Center for Palliative Care Studies)
Yano EM (VA GLAHS)
Wang M (VA GLAHS)
Ettner SL (UCLA)
Objectives:
Because we know little about how to best integrate palliative care within the continuum of other services, we sought:
1)To understand the extent to which generalists and specialists share responsibility for outpatient end-of-life care.
2)To examine the relationship of serious medical conditions to the distribution of outpatient care.
Methods:
We constructed a cohort of all California veterans who died in 2000 excluding nonusers of VA services and continuous nursing home residents the year prior to death. Using Austin data linked to death certificates, we determined the prevalence of metastatic cancer, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), end-stage liver disease (ESLD), end-stage renal disease (ESRD), HIV, dementia, and numbers of visits to general internists and geriatricians versus medical-surgical subspecialists. Controlling for age, gender, and ethnicity, we examined the relationship between diagnoses and the outcomes total generalist and total specialty visits (two-part models), and the proportion of generalist to total outpatient visits (generalized ordered logit).
Results:
Results: Of 8627 veterans, 95% had an outpatient visit during the last year of life. We determined total generalist (mean 4.33, median 2) and subspecialty (mean 7.90, median 3) visits. The adjusted differences in total generalist visits (HIV -0.42; metastatic cancer 1.87; ESLD 1.90; COPD 2.78; CHF 3.45; dementia 4.97) and total specialist visits (dementia 0.88; ESLD 2.04; COPD 3.50; CHF 5.22; metastatic cancer 7.52; HIV 7.73; ESRD 36.25) associated with each diagnosis varied substantially. The predicted probability of receiving predominantly or only specialty care during the last year of life varied from 0.50 (dementia), 0.58 (COPD), 0.58 (ESLD), 0.81 (ESRD), 0.81 (metastatic cancer) to 0.83 (HIV).
Implications:
The outpatient setting is the most common site of care during the last year of life during which most patients have multiple visits to both generalists and specialists. Predominantly or only specialty care was more common for all conditions except dementia.
Impacts:
1)End-of-life improvement efforts must address the outpatient setting.
2)Both specialists and generalists must be engaged in efforts to improve end-of-life care, because for many patients, care is delivered almost entirely by either specialists or generalists.
3)Consideration of how to better address end-of-life care in specialty settings is especially important for advanced cancer, HIV, ESRD, and CHF.
