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Associations between physician home visits for the dying and place of death: A population-based retrospective cohort study.

ABSTRACT: While most individuals wish to die at home, the reality is that most will die in hospital.To determine whether receiving a physician home visit near the end-of-life is associated with lower odds of death in a hospital.Observational retrospective cohort study, examining location of death and health care in the last year of life.Population-level study of Ontarians, a Canadian province with over 13 million residents. All decedents from April 1, 2010 to March 31, 2013 (n = 264,754).More than half of 264,754 decedents died in hospital: 45.7% died in an acute care hospital and 7.7% in complex continuing care. After adjustment for multiple factors-including patient illness, home care services, and days of being at home-receiving at least one physician home visit from a non-palliative care physician was associated with a 47% decreased odds (odds-ratio, 0.53; 95%CI: 0.51-0.55) of dying in a hospital. When a palliative care physician specialist was involved, the overall odds declined by 59% (odds ratio, 0.41; 95%CI: 0.39-0.43). The same model, adjusting for physician home visits, showed that receiving palliative home care was associated with a similar reduction (odds ratio, 0.49; 95%CI: 0.47-0.51).Location of death is strongly associated with end-of-life health care in the home. Less than one-third of the population, however, received end-of-life home care or a physician visit in their last year of life, revealing large room for improvement.

SUBMITTER: Tanuseputro P

PROVIDER: S-EPMC5813907 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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Associations between physician home visits for the dying and place of death: A population-based retrospective cohort study.

Tanuseputro Peter P Beach Sarah S Chalifoux Mathieu M Wodchis Walter P WP Hsu Amy T AT Seow Hsien H Manuel Douglas G DG

PloS one 20180215 2

<h4>Background</h4>While most individuals wish to die at home, the reality is that most will die in hospital.<h4>Aim</h4>To determine whether receiving a physician home visit near the end-of-life is associated with lower odds of death in a hospital.<h4>Design</h4>Observational retrospective cohort study, examining location of death and health care in the last year of life.<h4>Setting/participants</h4>Population-level study of Ontarians, a Canadian province with over 13 million residents. All dec ...[more]

PMID: 29447291

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Project description:BackgroundVisits to the emergency department are critical opportunities to engage individuals after an overdose. We sought to estimate and compare the 12-month mortality between persons with visits to the emergency department related to opioid overdose and those with non-overdose-related visits.MethodsWe conducted a retrospective cohort study using the Provincial Overdose Cohort, which contains data for patients in British Columbia who had an opioid-related overdose between 2015 and 2017, along with a 20% random sample of BC residents for comparison. We examined all nonfatal visits to the emergency department between Jan. 1, 2015, and Dec. 31, 2016, among persons aged 14 to 74 years and compared the 12-month mortality between those with overdose-related visits and those with non-overdose-related visits. We estimated the hazard ratio for death, with adjustment for age, sex, comorbidity and disposition (discharged or left against medical advice).ResultsWe included 3593 persons with overdose-related visits and 216 453 with non-overdose-related visits to the emergency department. Those with overdose-related visits were younger, were predominantly male and had more mental health conditions. The 12-month crude mortality probability was 5.4% (95% confidence interval [CI] 4.7%-6.2%) in this group and 1.7% (95% CI 1.6%-1.8%) among those with non-overdose-related visits. After adjustment, for persons who were discharged, the 12-month mortality hazard was 3.5 (95% CI 3.0-4.2) times higher among those with overdose-related visits than those with non-overdose-related visits. For persons who left against medical advice, the mortality hazard was 7.1 (95% CI 4.0-12.5) times higher among those with opioid overdose.InterpretationAmong persons with overdose-related visits to the emergency department, 12-month mortality was higher than among those with non-overdose-related visits. Overdose-related visits should prompt urgent evidence-based interventions (e.g., take-home naloxone kits, buprenorphine-naloxone induction) to prevent future deaths.

Project description:BackgroundPsychotherapy is recommended as a first-line treatment for the management of common psychiatric disorders. The objective of this study was to evaluate the availability of publicly funded psychotherapy provided by physicians in Ontario by describing primary care physicians (PCPs) and psychiatrists whose practices focus on psychotherapy and comparing them to PCPs and psychiatrists whose practices do not.MethodsThis was a population-based retrospective cohort study. We included all PCPs and psychiatrists in Ontario who submitted at least 1 billing claim to the Ontario Health Insurance Plan between Apr. 1, 2015, and Mar. 31, 2016, and categorized them as psychotherapists if at least 50% of their outpatient billings were related to the provision of psychotherapy. We measured practice characteristics such as total number of patients and new patients, and average visit frequency for 4 physician categories: PCP nonpsychotherapists, PCP psychotherapists, psychiatrist nonpsychotherapists and psychiatrist psychotherapists. We also measured access to care for people with urgent need for mental health services.ResultsOf 12 772 PCPs, 404 (3.2%) were PCP psychotherapists; of 2150 psychiatrists, 586 (27.3%) were psychotherapists. Primary care physician nonpsychotherapists had the highest number of patients and number of new patients, followed by psychiatrist nonpsychotherapists, PCP psychotherapists and psychiatrist psychotherapists. Primary care physician nonpsychotherapists had the lowest average annual number of visits per patient, whereas both types of psychotherapists had a much greater number of visits per patient. Primary care physician and psychiatrist nonpsychotherapists saw about 25% of patients with urgent needs for mental health services, whereas PCP and psychiatrist psychotherapists saw 1%-3% of these patients.InterpretationPhysicians who provide publicly funded psychotherapy in Ontario see a small number of patients, and they see few of those with urgent need for mental health services. Our findings suggest that improving access to psychotherapy will require the development of alternative strategies.

Project description:ObjectiveDiagnostic error is a key healthcare concern and can result in substantial morbidity and mortality. Yet no study has investigated the relationship between adverse outcomes resulting from diagnostic errors and one potentially large contributor to these errors: deficiencies in diagnostic knowledge. Our objective was to measure that associations between diagnostic knowledge and adverse outcomes after visits to primary care physicians that were at risk for diagnostic errors.Setting/participants1410 US general internists who recently took their American Board of Internal Medicine Maintenance of Certification (ABIM-IM-MOC) exam treating 42 407 Medicare beneficiaries who experienced 48 632 'index' outpatient visits for new problems at risk for diagnostic error because the presenting problem (eg, dizziness) was related to prespecified diagnostic error sensitive conditions (eg, stroke).Outcome measures90-day risk of all-cause death, and, for outcome conditions related to the index visits diagnosis, emergency department (ED) visits and hospitalisations.DesignUsing retrospective cohort study design, we related physician performance on ABIM-IM-MOC diagnostic exam questions to patient outcomes during the 90-day period following an index visit at risk for diagnostic error after controlling for practice characteristics, patient sociodemographic and baseline clinical characteristics.ResultsRates of 90-day adverse outcomes per 1000 index visits were 7 for death, 11 for hospitalisations and 14 for ED visits. Being seen by a physician in the top versus bottom third of diagnostic knowledge during an index visit for a new problem at risk for diagnostic error was associated with 2.9 fewer all-cause deaths (95% CI -5.0 to -0.7, p=0.008), 4.1 fewer hospitalisations (95% CI -6.9 to -1.2, p=0.006) and 4.9 fewer ED visits (95% CI -8.1% to -1.6%, p=0.003) per 1000 visits.ConclusionHigher diagnostic knowledge was associated with lower risk of adverse outcomes after visits for problems at heightened risk for diagnostic error.

Dataset Information

Associations between physician home visits for the dying and place of death: A population-based retrospective cohort study.

Publications

Associations between physician home visits for the dying and place of death: A population-based retrospective cohort study.

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