@article {8684, title = {Racial and Ethnic Differences in End-of-Life Medicare Expenditures.}, journal = {Journal of the American Geriatrics Society}, volume = {64}, year = {2016}, pages = {1789-1797}, abstract = {

OBJECTIVES: To determine to what extent demographic, social support, socioeconomic, geographic, medical, and End-of-Life (EOL) planning factors explain racial and ethnic variation in Medicare spending during the last 6~months of life.

DESIGN: Retrospective cohort study.

SETTING: Health and Retirement Study (HRS).

PARTICIPANTS: Decedents who participated in HRS between 1998 and 2012 and previously consented to survey linkage with Medicare claims (N~=~7,105).

MEASUREMENTS: Total Medicare expenditures in the last 180~days of life according to race and ethnicity, controlling for demographic factors, social supports, geography, illness burden, and EOL planning factors, including presence of advance directives, discussion of EOL treatment preferences, and whether death had been expected.

RESULTS: The analysis included 5,548 (78.1\%) non-Hispanic white, 1,030 (14.5\%) non-Hispanic black, and 331 (4.7\%) Hispanic adults and 196 (2.8\%) adults of other race or ethnicity. Unadjusted results suggest that average EOL Medicare expenditures were $13,522 (35\%, P~<~.001) more for black decedents and $16,341 (42\%, P~<~.001) more for Hispanics than for whites. Controlling for demographic, socioeconomic, geographic, medical, and EOL-specific factors, the Medicare expenditure difference between groups fell to $8,047 (22\%, P~<~.001) more for black and $6,855 (19\%, P~<~.001) more for Hispanic decedents than expenditures for non-Hispanic whites. The expenditure differences between groups remained statistically significant in all models.

CONCLUSION: Individuals-level factors, including EOL planning factors do not fully explain racial and ethnic differences in Medicare spending in the last 6~months of life. Future research should focus on broader systemic, organizational, and provider-level factors to explain these differences.

}, keywords = {African Continental Ancestry Group, Aged, Aged, 80 and over, Cohort Studies, Comorbidity, Cross-Cultural Comparison, Ethnic Groups, European Continental Ancestry Group, Female, Health Care Surveys, Health Expenditures, Hispanic Americans, Humans, Life Support Care, Longitudinal Studies, Male, Medicare, Rate Setting and Review, Social Support, Socioeconomic factors, Terminal Care, United States}, issn = {1532-5415}, doi = {10.1111/jgs.14263}, author = {Byhoff, Elena and Tamara B Harris and Kenneth M. Langa and Theodore J Iwashyna} } @article {8125, title = {Factors influencing the use of intensive procedures at the end of life.}, journal = {J Am Geriatr Soc}, volume = {62}, year = {2014}, note = {Times Cited: 0 0}, month = {2014 Nov}, pages = {2088-94}, publisher = {62}, abstract = {

OBJECTIVES: To examine individual and regional factors associated with the use of intensive medical procedures in the last 6 months of life.

DESIGN: Retrospective cohort study.

SETTING: The Health and Retirement Study (HRS), a longitudinal nationally representative cohort of older adults.

PARTICIPANTS: HRS decedents aged 66 and older (N = 3,069).

MEASUREMENTS: Multivariable logistic regression was used to evaluate associations between individual and regional factors and receipt of five intensive procedures: intubation and mechanical ventilation, tracheostomy, gastrostomy tube insertion, enteral and parenteral nutrition, or cardiopulmonary resuscitation in the last 6 months of life.

RESULTS: Approximately 18\% of subjects (n = 546) underwent at least one intensive procedure in the last 6 months of life. Characteristics significantly associated with lower odds of an intensive procedure included aged 85-94 (vs 65-74, adjusted odds ratio (AOR) = 0.67, 95\% confidence interval (CI) = 0.51-0.90), Alzheimer{\textquoteright}s disease (AOR = 0.71, 95\% CI = 0.54-0.94), cancer (AOR = 0.60, 95\% CI = 0.43-0.85), nursing home residence (AOR = 0.70, 95\% CI = 0.50-0.97), and having an advance directive (AOR = 0.71, 95\% CI = 0.57-0.89). In contrast, living in a region with higher hospital care intensity (AOR = 2.16, 95\% CI = 1.48-3.13) and black race (AOR = 2.02, 95\% CI = 1.52-2.69) each doubled one{\textquoteright}s odds of undergoing an intensive procedure.

CONCLUSION: Individual characteristics and regional practice patterns are important determinants of intensive procedure use in the last 6 months of life. The effect of nonclinical factors highlights the need to better align treatments with individual preferences.

}, keywords = {Advance directives, Aged, Aged, 80 and over, Alzheimer disease, Cause of Death, Chronic disease, Critical Care, Female, Homes for the Aged, Humans, Life Support Care, Logistic Models, Male, Multivariate Analysis, Neoplasms, Nursing homes, Odds Ratio, Terminal Care, United States, Utilization Review}, issn = {1532-5415}, doi = {10.1111/jgs.13104}, author = {Evan C Tschirhart and Qingling Du and Amy Kelley} }