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Regional variation in the association between advance directives and end-of-life Medicare expenditures.
JAMA. 2011 Oct 05; 306(13):1447-53.JAMA

Abstract

CONTEXT

It is unclear if advance directives (living wills) are associated with end-of-life expenditures and treatments.

OBJECTIVE

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.

DESIGN, SETTING, AND PATIENTS

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.

MAIN OUTCOME MEASURES

Medicare expenditures, life-sustaining treatments, hospice care, and in-hospital death over the last 6 months of life.

RESULTS

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.

CONCLUSION

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.

Authors+Show Affiliations

Institute for Social Research, University of Michigan, Ann Arbor, MI 48104, USA. lnichola@umich.eduNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Research Support, N.I.H., Extramural

Language

eng

PubMed ID

21972306

Citation

Nicholas, Lauren Hersch, et al. "Regional Variation in the Association Between Advance Directives and End-of-life Medicare Expenditures." JAMA, vol. 306, no. 13, 2011, pp. 1447-53.
Nicholas LH, Langa KM, Iwashyna TJ, et al. Regional variation in the association between advance directives and end-of-life Medicare expenditures. JAMA. 2011;306(13):1447-53.
Nicholas, L. H., Langa, K. M., Iwashyna, T. J., & Weir, D. R. (2011). Regional variation in the association between advance directives and end-of-life Medicare expenditures. JAMA, 306(13), 1447-53. https://doi.org/10.1001/jama.2011.1410
Nicholas LH, et al. Regional Variation in the Association Between Advance Directives and End-of-life Medicare Expenditures. JAMA. 2011 Oct 5;306(13):1447-53. PubMed PMID: 21972306.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Regional variation in the association between advance directives and end-of-life Medicare expenditures. AU - Nicholas,Lauren Hersch, AU - Langa,Kenneth M, AU - Iwashyna,Theodore J, AU - Weir,David R, PY - 2011/10/6/entrez PY - 2011/10/6/pubmed PY - 2011/10/7/medline SP - 1447 EP - 53 JF - JAMA JO - JAMA VL - 306 IS - 13 N2 - CONTEXT: It is unclear if advance directives (living wills) are associated with end-of-life expenditures and treatments. OBJECTIVE: 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. DESIGN, SETTING, AND PATIENTS: 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. MAIN OUTCOME MEASURES: Medicare expenditures, life-sustaining treatments, hospice care, and in-hospital death over the last 6 months of life. RESULTS: 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. CONCLUSION: 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. SN - 1538-3598 UR - https://www.unboundmedicine.com/medline/citation/21972306/Regional_variation_in_the_association_between_advance_directives_and_end_of_life_Medicare_expenditures_ L2 - https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2011.1410 DB - PRIME DP - Unbound Medicine ER -