Does Primary Care Model Effect Healthcare at the End of Life? A Population-Based Retrospective Cohort Study

BACKGROUND: Comprehensive primary care may enhance patient experience at end of life. OBJECTIVE: To examine whether belonging to different models of primary care is associated with end-of-life healthcare use and outcomes. DESIGN: Retrospective population cohort study, using health administrative databases to describe health services and costs in the last six months of life across three primary care models: enrolled to a physician remunerated mainly by capitation, with incentives for comprehensive care and access in some to allied health practitioners (Capitation); remunerated mainly from fee-for-service (FFS) with smaller incentives for comprehensive care (Enhanced FFS); and not enrolled, seeing physicians remunerated solely through FFS (Traditional FFS). SETTING: People who died from April 1, 2010 to March 31, 2013 in Ontario, Canada. MEASURES: Health service utilization, costs, and place of death. RESULTS: Approximately two-thirds (62.7%) of decedents had more contact with a specialist than family physician. Those in Capitation models were more likely to have the majority of physician services provided by a family physician (44.9% vs. 38.6% in Enhanced FFS and 34.3% in Traditional FFS) and received more home care service days (mean 27.2 vs. 24.2 in Enhanced FFS and 21.7 in Traditional FFS). And 22.5% had a home visit by a family physician. Controlling for potential confounders, decedents spent significantly more days in an institution in Enhanced FFS (1.1, 95% confidence interval [CI]: 0.9-1.5) and Traditional FFS (2.2, 95% CI: 1.8-2.6) than in Capitation. CONCLUSION: Decedents in comprehensive primary care models received more care in the community and spent less time in institutions.