Socio-demographic and clinical characteristics of the study sample
68,735 patients meeting the inclusion criteria were extracted from the CPRD database. After exclusion of 212 patients with ambiguous date of diagnostic information, the final study sample comprised of 68,523 patients. 71% of the patients were aged 70 years or above and 45% were women (Table 1). Lung cancer comprised over one third of the study sample, followed by colorectal cancer (24.2%) and roughly equal number of breast and prostate cancer. 75.1% of the patients had one or more comorbid conditions. Among all patients, 29.4% survived less than 6 months from their cancer diagnosis and 4.3% survived longer than 10 years. The study participants were dominated by the patients died in recent periods (2005-2014, 75.3%). Relatively more patients were from affluent regions (27.7% IMD1/2 vs 21.9% IMD 4/5). The study sample primarily comprised patients from practices in England (77.5%), followed by Scotland (10.3%), Wales (8.6%) and Northern Ireland (3.2%).
Patients’ characteristics by status of palliative care needs recognised
Nearly half of the patients (45.5%) were identified as having palliative care needs. Patients in the PC group died relatively young - 35% died before the age of 70 compared to 24% in non-PC group. There were more lung cancer patients in PC than in non-PC group (42.2 vs 32.1%). The gender distribution and median survival (15 months) were similar between two groups. Overall, approximately three in four (75.1%) patients had one or more comorbid conditions and patients in the PC group had slightly higher level of comorbidity (75.8%) than in non-PC group (74.6%). PC group had relatively more patients from more affluent areas (IMD 1+2: 28.8% versus 26.7%).
Patterns of GP service use
GP consultations
Of the 5,819,161 consultations happening in the last year of life, 3,031,734 (52.1%) were included in this analysis. The sample of analysis was formed after excluding those consultations that were primarily for administerative purpose (i.e. having no direct patient contacts or those unknown types of consultations (totalling 2,787,427, 47.9%). A patient on average received 43.0 consultations in the last year of life (Standard deviation (SD): 31.7; Median: 36, Interquartile range (IQR): 36). Consultations in the last year of a patient’s life rarely took place at the usual residences of patients (4.4%). Up to one third (29.5%) of the patients had 10 or more monthly consultations in the final year, and 15.7% in the final month. Patients in PC group received more consultations than those in non-PC group (53.3, SD: 34.4 versus 34.9, SD: 26.3) and this remained true throughout the last 12 months of life (Figure 1). In both groups, the proportion of patients receiving 10+ consultations peaked at the last 2nd month with a sharp drop in the month before death. The monthly mean number of consultations showed a similar pattern.
GP prescriptions
95.8% of the 68,523 patients in total had 5,074,178 valid GP prescribing records in the last year of life. These patients were exposed to 1313 drug groups in the year before death. A patient received a total of 71.5 prescriptions (SD: 68.0; Median: 57, IQR: 63) and 21.3 different drugs (SD: 13.0; Median: 20, IQR: 17) in the final year. The top five commonly prescribed drug groups were opioid analgesics (6.4%), proton pump inhibitors (4.5%), Non-opioid and compound analgesics (4.0%), antiplatelet drugs (3.9%) and Statins (3.1%). In the last 12 months, the proportion of patients receiving 10 or more monthly prescriptions from their GPs reached a peak (36.6%) in the penultimate month before death, then fell to the lowest level (15.4%) in the last month. Over the last 12 months, the GP prescribing rate was consistently higher in the PC group than in non-PC group (Figure 2).
GP referrals
58% of the study participants had at least one referral in the last year (total N= 89,975). The referral rate showed a slight increasing trend along with the closeness to death but remained at a lower level (7.0 to 11.8%) and dropped to the lowest (5.0%) in the month before death (Figure 3). The average number of referral specialities fluctuated in a small range (1.2 to 1.3). Patients in PC group had a slightly higher percentage with at least one end-of-life referral record and a higher average number of referring specialities than those in the non-PC group. Even with between 31 and 45% missing or non-specific specialty data, the referred specialities were broad and spanned two third (60 to 67) of the 93 listed specialties. The commonly referred specialties were general surgery or general medicine most of the time in the last year of life, and only in the last month palliative medicine became the second most referred specialty.
Factors associated with GP service use and PC status
GP service use
The magnitude of association between patient characteristics and service use as measured by the adjusted risk ratio (aRR) was shown in Table 2. Patients in PC group had more GP consultations (aRR 1.30, 1.29-1.32), prescriptions (aRR 1.17, 1.16-1.19) and more likely to be referred for other care services (aRR 1.22, 1.19-1.26) than those in non-PC group. Increasing age was associated with fewer GP consultations but more prescriptions and a higher chance of GP referral. The effect of age on consultation started from 50-59 age group (aRR 0.96, 0.93 to 0.99) to the strongest in 90+ group (aRR 0.77, 0.75 to 0.80). Compared to those under 50 years old, patients aged over 50 received more prescriptions with a clear dose-response relationship (aRRs 1.09 to 1.44); while those aged between 50 and 89 were more likely to be referred to other care services (aRRs 1.08 to 1.16). Men had less consultations (aRR 0.96, 0.95 to 0.97) and prescriptions (aRR 0.90, 0.89 and 0.92) than women.
Patients with prostate cancer received more consultations, more prescriptions and a higher chance of referral than patients with any other cancers (aRRs 1.14 to 1.21). Compared to lung cancer, colorectal cancer received more prescriptions and a higher chance of being referred (aRRs 1.04-1.05. Comorbidity was positively associated with consultations, prescriptions and referrals (aRRs 1.07 to 2.03), all with a dose-response relationship (p for trend <0.0001).
Patients who survived less than 5 years since their cancer diagnosis received more GP consultations (aRRs 1.05 to 1.31) than those who survived more than 5 years. However, only those who survived in between 6 and 36 months had more prescriptions (aRRs 1.05-1.07) than those who survived less than 6 months or longer than 3 years. Patients with a shorter survival (<1 year) had a higher chance of being referred to other specialities (aRRs 1.41 to 1.53) than those who survived more than 1 year. Patients who died in earlier years (2000-2009) had fewer consultations (aRRs 0.64 to 0.86) and fewer prescriptions (aRRs 0.79 to 0.91) in comparison to those who died in the more recent period (2010-2014). However, patients who died in 2000-2004 had the highest chance (aRR 1.13, 1.01 to 1.25) and in 2005-2009 the lowest chance (aRR 0.93, 0.88 to 0.97) of GP referral.
Practices in Northern Ireland (aRR 1.34, 1.09 to 1.64) appeared to offer more and in Wales (aRR 0.85, 0.75-0.96) less consultations to their patients than practices in England or Scotland. GPs in Wales prescribed more (aRR 1.15, 1.08-1.22) and in Scotland prescribed less for their patients (aRR 0.87, 0.83-0.91) than GPs in England or Northern Ireland. Practices in Wales were more likely (aRR 1.23, 1.01-1.49) and in Scotland less likely(aRR 0.77, 0.61-0.97) to refer their patients than their counterparterners in England or Northern Ireland.
Palliative care needs recognised
Older age (≥60 years), male gender and cancers of colorectal, prostate or breast were associated with a lower chance of having palliative care needs recognised. There was a dose-response relationship between age at death and the chance of PC group membership – aRRs ranging from 0.53 in 90+ to 0.89 in 60-69 age group. Patients with comorbidities were more likely to be in the PC group (aRRs 1.07 to 1.08). Patients who survived their cancer between 6 and 60 months had the highest chance of being in the PC group (aRRs 1.32 to 1.41), followed by those who survived less than 6 months or 5 to 10 years (aRRs 1.11 to 1.17). Those who died in 2000-2004 had half the probability of a patient having palliative care needs recognised (aRR versus 2010-2014: 0.48, 0.45 to 0.51), while the period 2005-2009 was associated with approximately 20% reduction of that chance (aRR 0.81, 0.78 to 0.83). There was no geographical differences in the chance of having palliative care needs recognised.
Sensitivity analyses
Sensitivity analyses (Appendix Tables 1-4) demonstrated similar results. Patients living in the deprived areas were less likely to having palliative care needs recognised and they also received less prescriptions from their GPs. There was no statistically significant difference in the number of consultations or referrals by social economic status.