Continuity of Care and Intensive Care Unit Use at the End of Life

Abstract

Background There is increasing concern about discontinuity of care across transitions (e.g. from home to hospital) and how that might affect appropriate medical management. We examined the changes over time in outpatient to inpatient continuity in individuals hospitalized with advanced lung cancer and its relationship to end of life ICU use. Methods Retrospective analysis of the linked Surveillance, Epidemiology and End Results (SEER) – Medicare database. Subjects were 21,183 Medicare beneficiaries aged 66 years or older diagnosed with Stage IIIB or IV lung cancer between January 1, 1992 and December 31, 2002 who died within a year of diagnosis from 1992 through 2003. Outpatient to inpatient continuity is defined as an inpatient visit by the patient's usual care provider during the last hospitalization. The primary outcome measure is ICU use during the last hospitalization. Results Outpatient to inpatient continuity decreased from 60.1% in 1992 to 51.5% in 2002 (p<0.001). Factors associated with decreased continuity included: male gender, black race, low socioeconomic status, being unmarried, treatment by a hospitalist, and treatment in a teaching hospital. ICU use increased by 5.8% per year from 1993–2002. After adjusting for patient characteristics, patients with outpatient to inpatient continuity had a 25.1% reduced odds of spending time in an ICU during the terminal hospitalization. Conclusion Outpatient to inpatient continuity of care declined during the 1990s and early 2000s. Patients with terminal lung cancer who experienced continuity of care across the outpatient to hospital settings were less likely to spend time in the ICU prior to death.

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