Determinants of Medical Expenditures in the Last 6 Months of Life

TitleDeterminants of Medical Expenditures in the Last 6 Months of Life
Publication TypeJournal Article
Year of Publication2011
AuthorsKelley, AS, Ettner, SL, R. Morrison, S, Du, Q, Wenger, NS, Sarkisian, CA
JournalAnnals of Internal Medicine
Volume154
Issue4
Pagination235
Date PublishedMar-02-2012
ISSN Number0003-4819
KeywordsEnd of life decisions, Medical Expenses, Mortality, Older Adults
Abstract

Background
End-of-life medical expenditures exceed costs during other periods, vary across regions, and are likely to be unsustainable. Identifying determinants of expenditure variation may reveal opportunities for reducing costs.

Objectives
To 1) identify patient-level determinants of Medicare expenditures at end-of-life and 2) determine these factors’ contributions to expenditure variation while accounting for regional characteristics. We hypothesized that race/ethnicity, social support and functional status are independently associated with treatment intensity, controlling for regional characteristics, and that individual characteristics account for a substantial proportion of expenditure variation.

Design
Using Health and Retirement Study (HRS), Medicare claims and Dartmouth Atlas of Health Care data, we modeled relationships between expenditures and patient and regional characteristics.

Participants and Setting
HRS decedents 65.5 years or older (n=2394), 2000–2006.

Measurement
Medicare expenditures in last 6 months of life were estimated in a series of 2-level multivariable regression models including 1) patient, 2) regional, and 3) patient and regional characteristics.

Results
Decline in function (rate ratio 1.64, 95%CI 1.46–1.83), Hispanic ethnicity (1.50, 1.22–1.85), African American race (1.43, 1.25–1.64), and certain chronic diseases including diabetes (1.16, 1.06–1.27), were associated with higher expenditures. Nearby family (0.90, 0.82–0.98) and dementia (0.78, 0.71–0.87) were associated with lower expenditures and advance care planning had no association. Regional characteristics, including end-of-life practice patterns (1.09, 1.06–1.14) and hospitals beds per capita (1.01, 1.00–1.02), were associated with higher expenditures. Patient characteristics explained 10% of overall variance and retained statistically significant relationships with expenditures after controlling for regional characteristics.

Limitations
Decedent sample, proxy informants, large proportion of variation remains unexplained.

Conclusions
Patient characteristics: functional decline, race/ethnicity, chronic disease, and nearby family, are important determinants of expenditures at end-of-life, independent of regional characteristics.

URLhttp://annals.org/article.aspx?doi=10.7326/0003-4819-154-4-201102150-00004
DOI10.7326/0003-4819-154-4-201102150-00004
Short TitleAnn Intern Med
Citation Key8752