Journal of General Internal Medicine

, Volume 23, Issue 9, pp 1330–1335 | Cite as

Can Primary Care Visits Reduce Hospital Utilization Among Medicare Beneficiaries at the End of Life?

  • Andrea C. Kronman
  • Arlene S. Ash
  • Karen M. Freund
  • Amresh Hanchate
  • Ezekiel J. Emanuel
Original Article



Medical care at the end of life is often expensive and ineffective.


To explore associations between primary care and hospital utilization at the end of life.


Retrospective analysis of Medicare data. We measured hospital utilization during the final 6 months of life and the number of primary care physician visits in the 12 preceding months. Multivariate cluster analysis adjusted for the effects of demographics, comorbidities, and geography in end-of-life healthcare utilization.


National random sample of 78,356 Medicare beneficiaries aged 66+ who died in 2001. Non-whites were over-sampled. All subjects with complete Medicare data for 18 months prior to death were retained, except for those in the End Stage Renal Disease program.


Hospital days, costs, in-hospital death, and presence of two types of preventable hospital admissions (Ambulatory Care Sensitive Conditions) during the final 6 months of life.


Sample characteristics: 38% had 0 primary care visits; 22%, 1–2; 19%, 3–5; 10%, 6–8; and 11%, 9+ visits. More primary care visits in the preceding year were associated with fewer hospital days at end of life (15.3 days for those with no primary care visits vs. 13.4 for those with ≥9 visits, P < 0.001), lower costs ($24,400 vs. $23,400, P < 0.05), less in-hospital death (44% vs. 40%, P < 0.01), and fewer preventable hospitalizations for those with congestive heart failure (adjusted odds ratio, aOR = 0.82, P < 0.001) and chronic obstructive pulmonary disease (aOR = 0.81, P = 0.02).


Primary care visits in the preceding year are associated with less, and less costly, end-of-life hospital utilization. Increased primary care access for Medicare beneficiaries may decrease costs and improve quality at the end of life.

Key words

end-of-life care health services research primary care 


  1. 1.
    Hogan C, Lunney J, Gabel J, Lynn J. Medicare beneficiaries’ costs of care in the last year of life. Health Aff. 2001;204188–95.CrossRefGoogle Scholar
  2. 2.
    Edwards C, DeHaven T. War betweeen the generations: federal spending on the elderly set to explode. In: C. Institute, eds. Policy Analysis. Washington D.C.; 2003: 1–22.Google Scholar
  3. 3.
    Approaching Death: Improving Care at the End of Life. Washington D.C.: National Academy Press; 1997.Google Scholar
  4. 4.
    Ezekiel EJ. Cost savings at the end of life: What do the data show? JAMA. 1996;275241907–14.CrossRefGoogle Scholar
  5. 5.
    Campbell D, Lynn J, Louis T, Shugarman L. Medicare program expenditures associated with hospice use. Ann Intern Med. 2004;140:269–77.PubMedGoogle Scholar
  6. 6.
    Degenholtz HB, Rhee Y, Arnold RM. Brief communication: the relationship between having a living will and dying in place. Ann Intern Med. 2004;1412113–7.PubMedGoogle Scholar
  7. 7.
    SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients: the study to understand prognoses and preferences for outcomes and risks of treatments. JAMA. 1995;274:1591–8.CrossRefGoogle Scholar
  8. 8.
    Patrick D, Curtis R, Engelberg R, Nielsen E, McCown E. Measuring and improving the quality of dying and death. Ann Intern Med. 2003;1392410–5.PubMedGoogle Scholar
  9. 9.
    Burge F, Lawson B, Johnston G. Family physician continuity of care and emergency department use in end-of-life cancer care. Med Care. 2003;418992–1001.PubMedCrossRefGoogle Scholar
  10. 10.
    Burge F, Lawson B, Johnston G, Cummings I. Primary care continuity and location of death for those with cancer. J Palliat Med. 2003;66911–8.PubMedCrossRefGoogle Scholar
  11. 11.
    De Maeseneer JM, De Prins L, Gosset C, Heyerick J. Provider continuity in family medicine: does it make a difference for total health care costs? Ann Fam Med. 2003;13144–8.PubMedCrossRefGoogle Scholar
  12. 12.
    Gill JM, Mainous AG 3rd. The role of provider continuity in preventing hospitalizations. Arch Fam Med. 1998;74352–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Saultz JW, Albedaiwi W. Interpersonal continuity of care and patient satisfaction: a critical review. Ann Fam Med. 2004;25445–51.PubMedCrossRefGoogle Scholar
  14. 14.
    Cabana MD, Jee SH. Does continuity of care improve patient outcomes? J Fam Pract. 2004;5312974–80.PubMedGoogle Scholar
  15. 15.
    Ash AS, Ellis RP, Pope GC, et al. Using diagnoses to describe populations and predict costs. Health Care Financ Rev. 2000;2137–28.PubMedGoogle Scholar
  16. 16.
    Burns RB, McCarthy EP, Freund KM, et al. Black women receive less mammography even with similar use of primary care. Ann Intern Med. 1996;125:173–82.PubMedGoogle Scholar
  17. 17.
    Keating NL, Landrum MB, Ayanian JZ, et al. The association of ambulatory care with breast cancer stage at diagnosis among Medicare beneficiaries. J Gen Intern Med. 2005;20:38–44.PubMedCrossRefGoogle Scholar
  18. 18.
    Ricketts TC, Randolph R, Howard HA, Pathman D, Carey T. Hospitalization rates as indicators of access to primary care. Health & Place. 2001;7127–38.CrossRefGoogle Scholar
  19. 19.
    Agency for Healthcare Research and Quality. Refinement of the HCUP Quality Indicators. 2001 Summary, Technical Review Number 4. Available at: Accessed March 12, 2008.
  20. 20.
    Norman Levinsky M, Wei Yu P, Arlene Ash P, et al. Influence of age on medicare expenditures and medical care in the last year of life. JAMA. 2001;286111349–55.CrossRefGoogle Scholar
  21. 21.
    Valentin A, Jordan B, Lang T, Hiesmayr M, Metnitz PGH. Gender-related differences in intensive care: A multiple-center cohort study of therapeutic interventions and outcome in critically ill patients. Crit Care Med. 2003;3171901–7.PubMedCrossRefGoogle Scholar
  22. 22.
    Degenholtz HB, Thomas SB, Miller MJ. Race and the intensive care unit: disparities and preferences for end-of-life care. Crit Care Med. 2003;315 SupplS373–8.PubMedCrossRefGoogle Scholar
  23. 23.
    Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002;162202269–76.PubMedCrossRefGoogle Scholar
  24. 24.
    Ash AS, Posner MA, Speckman J, Franco S, Yacht AC, Bramwell L. Using claims data to examine mortality trends following hospitalization for heart attack in Medicare. Health Serv Res. 2003;3851253–62.PubMedCrossRefGoogle Scholar
  25. 25.
    Pritchard RS, Fisher ES, Teno JM, et al. Influence of patient preferences and local health system characteristics on the place of death. SUPPORT investigators. Study to understand prognoses and preferences for risks and outcomes of treatment. J Am Geriatr Soc. 1998;46101242–50.PubMedGoogle Scholar
  26. 26.
    Baicker K, Chandra A, Skinner JS, Wennberg JE. Who you are and where you live: how race and geography affect the treatment of medicare beneficiaries. Health Aff. 2004;(Suppl Web Exclusive):VAR33–44.Google Scholar
  27. 27.
    Wennberg JE, Fisher ES, Stukel TA, Skinner JS, Sharp SM, Bronner KK. Use of hospitals, physician visits, and hospice care during last six months of life among cohorts loyal to highly respected hospitals in the United States. BMJ. 2004;3287440607.PubMedCrossRefGoogle Scholar
  28. 28.
    Emanuel E, Emanuel L. The economics of dying–the illusion of cost savings at the end of life. N Engl J Med. 1994;3308540–4.PubMedCrossRefGoogle Scholar
  29. 29.
    Shugarman LR, Campbell DE, Bird CE, Gabel J, Louis TA, Lynn J. Differences in medicare expenditures during the last 3 years of life. J Gen Intern Med. 2004;192127–35.PubMedCrossRefGoogle Scholar
  30. 30.
    Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA. 2002;288151909–14.PubMedCrossRefGoogle Scholar
  31. 31.
    Grabowski DC, Stewart KA, Broderick SM, et al. Predictors of nursing home hospitalization: a review of the literature. Med Care Res Rev. 2008;6513–39.PubMedCrossRefGoogle Scholar
  32. 32.
    Weinberger M, Oddone EZ, Henderson WG. Does increased access to primary care reduce hospital readmissions? Veterans affairs cooperative study group on primary care and hospital readmission. N Engl J Med. 1996;334221441–7.PubMedCrossRefGoogle Scholar
  33. 33.
    Bodenheimer T. Primary care–will it survive? N Engl J Med. 2006;3559861–4.PubMedCrossRefGoogle Scholar
  34. 34.
    Fisher ES, Wennberg JE, Stukel TA, et al. Associations among hospital capacity, utilization, and mortality of US Medicare beneficiaries, controlling for sociodemographic factors. Health Serv Res. 34(6):1351–62.Google Scholar
  35. 35.
    Zhao Y, Ash AS, Ellis RP, Slaughter JP. Disease burden profiles: an emerging tool for managing managed care. Health Care Manage Sci. 2002;53211–9.CrossRefGoogle Scholar
  36. 36.
    Kronman A, Hanchate A, Ash AS. Improving risk adjustment for illness burden. J Gen Intern Med. 2007;22(s1). Abstract.Google Scholar
  37. 37.
    Health Care Financing Review: Medicare and Medicaid Statistical Supplement. US Dept. of Health and Human Services, Centers for Medicare and Medicaid Services, Office of Research, Development and Information, 2003.Google Scholar
  38. 38.
    Statement for the Record for Senate HELP Committee Hearing on Addressing Healthcare Workforce Issues for the Future (12-Feb-08): A Report from the American College of Physicians; 2008. Available at: Accessed March 12, 2008.

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Andrea C. Kronman
    • 1
  • Arlene S. Ash
    • 1
  • Karen M. Freund
    • 1
  • Amresh Hanchate
    • 1
  • Ezekiel J. Emanuel
    • 2
  1. 1.Women’s Health and Health Care Research Units, Section of General Internal Medicine, Evans Department of Medicine, and the Women’s Health Interdisciplinary Research CenterBoston University Medical CenterBostonUSA
  2. 2.Department of Clinical Bioethics, Warren Magnuson Clinical CenterNational Institutes of HealthBethesdaUSA

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