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.
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.
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.
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.
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.
Decedent sample, proxy informants, large proportion of variation remains unexplained.
Patient characteristics: functional decline, race/ethnicity, chronic disease, and nearby family, are important determinants of expenditures at end-of-life, independent of regional characteristics.