Ann Fam Med. 2022 Apr 1;20(20 Suppl 1):2751. doi: 10.1370/afm.20.s1.2751.
Context: Most people spend the majority of their last year of life at home or in a home-like setting, receiving outpatient healthcare. Increasing numbers of physicians and teams, including palliative care providers, may become involved in care in addition to a usual provider such as a family physician. Continuity of care (CoC) near the end of life, although considered a marker of quality of care, may be interrupted despite the provision of high-quality care. Objective: To describe continuity of outpatient physician care in the last 12 months of life and determine patient and illness-related factors associated with high continuity. Study Design: Retrospective cohort study. Datasets: Linked population-based health administrative databases for Ontario, Canada, held at ICES. Population: Decedents aged 19 years or older, who died between January 1, 2013, and December 31, 2017. Outcome Measures: Continuity of care scores for the last 12 months of life, using the Usual Provider continuity (UPC), Bice-Boxerman continuity (CoC), and Sequential Continuity (SECON) indices. Multivariate models were used to determine factors associated with higher continuity scores (>= 0.75). Results: Decedents (n=322,445) were on average 76.3 years of age, 47.8% were female, and 13.2% resided in rural regions. Decedents had a mean of 16.2 outpatient physician encounters in the last year of life, from a mean of 3.8 different physician specialties. Mean continuity indices' scores (1 being perfect) were low: UPC= 0.36, CoC= 0.31, and SECON= 0.37. Proportions of decedents with high continuity were: UPC= 12.6%, CoC= 9.6%, and SECON= 12.9%. Decedents who experienced a terminal illness (i.e., cancer) end-of-life trajectory were least likely to experience high UPC (OR= 0.32; 95% CI= 0.30, 0.34). Having six or more comorbidities (OR= 0.65; 95% CI= 0.63, 0.66), and being in the highest quintile of outpatient physician encounters (i.e., >22 visits) (OR= 0.28; 95% CI= 0.27, 0.29) were also negatively associated with high UPC. Results were similar for other indices. Conclusions: Decedents experience low continuity of outpatient physician care in the last year of life, especially those with cancer, comorbidities, and frequent physician visits. Modifications to existing indices may be needed to serve as end-of-life care quality indicators.
大多数人在生命的最后一年都在家里或类似家庭的环境中度过，并接受门诊医疗保健。除了家庭医生等常规提供者外，越来越多的医生和团队，包括姑息治疗提供者，可能会参与到治疗中。尽管连续性护理被认为是护理质量的标志，但尽管提供了高质量的护理，这种护理的连续性仍可能会中断。目的：描述生命最后 12 个月门诊医生护理的连续性，并确定与高连续性相关的患者和疾病相关因素。研究设计：回顾性队列研究。数据集：安大略省基于人群的健康行政数据库，由加拿大安大略省剑桥的ICES 持有。人群：19 岁或以上的死者，他们在 2013 年 1 月 1 日至 2017 年 12 月 31 日期间死亡。结局指标：生命最后 12 个月的护理连续性评分，使用常规提供者连续性（UPC）、Bice-Boxerman 连续性（CoC）和连续连续性（SECON）指数。使用多变量模型确定与更高连续性评分（>= 0.75）相关的因素。结果：死者（n=322445）的平均年龄为 76.3 岁，47.8%为女性，13.2%居住在农村地区。死者在生命的最后一年平均有 16.2 次门诊医生就诊，涉及平均 3.8 种不同的医生专业。平均连续性指数得分（1 为满分）较低：UPC=0.36，CoC=0.31，SECON=0.37。高连续性的死者比例为：UPC=12.6%，CoC=9.6%，SECON=12.9%。经历终末期疾病（即癌症）临终轨迹的死者最不可能经历高 UPC（OR=0.32；95%CI=0.30，0.34）。有六个或更多合并症（OR=0.65；95%CI=0.63，0.66）和处于最高五分位数的门诊医生就诊次数（即>22 次就诊）（OR=0.28；95%CI=0.27，0.29）也与高 UPC 呈负相关。其他指数的结果也类似。结论：死者在生命的最后一年经历了低水平的门诊医生护理连续性，尤其是那些患有癌症、合并症和频繁就诊的患者。可能需要对现有指数进行修改，以作为临终关怀质量指标。
