Regional variation in the association between advance directives and end-of-life Medicare expenditures.

TitleRegional variation in the association between advance directives and end-of-life Medicare expenditures.
Publication TypeJournal Article
Year of Publication2011
AuthorsNicholas, LHersch, Langa, KM, Iwashyna, TJ, Weir, DR
JournalJAMA
Volume306
Issue13
Pagination1447-53
Date Published2011 Oct 05
ISSN Number1538-3598
KeywordsAdvance directives, Aged, Aged, 80 and over, Data collection, Female, Health Expenditures, Hospice Care, Hospital Mortality, Hospitals, Humans, Kidney Failure, Chronic, Male, Medicare, Palliative care, Prospective Studies, Regression Analysis, Terminal Care, United States
Abstract

<p><b>CONTEXT: </b>It is unclear if advance directives (living wills) are associated with end-of-life expenditures and treatments.</p><p><b>OBJECTIVE: </b>To examine regional variation in the associations between treatment-limiting advance directive use, end-of-life Medicare expenditures, and use of palliative and intensive treatments.</p><p><b>DESIGN, SETTING, AND PATIENTS: </b>Prospectively collected survey data from the Health and Retirement Study for 3302 Medicare beneficiaries who died between 1998 and 2007 linked to Medicare claims and the National Death Index. Multivariable regression models examined associations between advance directives, end-of-life Medicare expenditures, and treatments by level of Medicare spending in the decedent's hospital referral region.</p><p><b>MAIN OUTCOME MEASURES: </b>Medicare expenditures, life-sustaining treatments, hospice care, and in-hospital death over the last 6 months of life.</p><p><b>RESULTS: </b>Advance directives specifying limits in care were associated with lower spending in hospital referral regions with high average levels of end-of-life expenditures (-$5585 per decedent; 95% CI, -$10,903 to -$267), but there was no difference in spending in hospital referral regions with low or medium levels of end-of-life expenditures. Directives were associated with lower adjusted probabilities of in-hospital death in high- and medium-spending regions (-9.8%; 95% CI, -16% to -3% in high-spending regions; -5.3%; 95% CI, -10% to -0.4% in medium-spending regions). Advance directives were associated with higher adjusted probabilities of hospice use in high- and medium-spending regions (17%; 95% CI, 11% to 23% in high-spending regions, 11%; 95% CI, 6% to 16% in medium-spending regions), but not in low-spending regions.</p><p><b>CONCLUSION: </b>Advance directives specifying limitations in end-of-life care were associated with significantly lower levels of Medicare spending, lower likelihood of in-hospital death, and higher use of hospice care in regions characterized by higher levels of end-of-life spending.</p>

URLhttp://proquest.umi.com.proxy.lib.umich.edu/pqdweb?did=2590187421andFmt=7andclientId=17822andRQT=309andVName=PQD
DOI10.1001/jama.2011.1410
User Guide Notes

http://www.ncbi.nlm.nih.gov/pubmed/21972306?dopt=Abstract

Endnote Keywords

Advance directives/Palliative care/Health care expenditures/Medicare

Endnote ID

62821

Alternate JournalJAMA
Citation Key7687
PubMed ID21972306
PubMed Central IDPMC3332047
Grant ListT32 AG000221 / AG / NIA NIH HHS / United States
U01 AG009740 / AG / NIA NIH HHS / United States
P30 DK092926 / DK / NIDDK NIH HHS / United States
R01 AG030155 / AG / NIA NIH HHS / United States
P30 AG012846 / AG / NIA NIH HHS / United States
R24 HD041028 / HD / NICHD NIH HHS / United States
UL1RR024986 / RR / NCRR NIH HHS / United States
K08 HL091249-03 / HL / NHLBI NIH HHS / United States
U01 AG09740 / AG / NIA NIH HHS / United States
T32 AG000221-19 / AG / NIA NIH HHS / United States
UL1 RR024986-02 / RR / NCRR NIH HHS / United States
R01 AG030155-01 / AG / NIA NIH HHS / United States
P30 AG012846-17 / AG / NIA NIH HHS / United States
K08 HL091249 / HL / NHLBI NIH HHS / United States
UL1 RR024986 / RR / NCRR NIH HHS / United States
U01 AG009740-21 / AG / NIA NIH HHS / United States