Health care near the end of life is an emotional topic and patient, family and physician preferences can range from the futilely heroic to minimal comfort care. Across the nation, end-of-life care is responsible for a great deal of overall spending, and that spending often does little to prolong life, much less improve the quality of what remains. Research presented in the Annals of Internal Medicine used Health and Retirement Survey data to ascertain the extent to which individual patient characteristics may account for higher spending and regional spending variations. (Annals Article)
The HRS data on participants who died was merged with their Medicare claims data and evaluated by hospital referral region, as defined by the Dartmouth Atlas. The Dartmouth end-of-life expenditure index for the region was used, as was its health care supply data. There were about 2394 decedents in the final sample. The primary outcome was total Medicare expenditures in the last 6 months of life. Variables examined included patient-level sociodemographics and functional status, including presence of chronic disease, and regional data on health care resources. The median expenditure was around $22,000; with a range of zero to $391,773.
Individual characteristics such as black or hispanic race, severe functional impairment, having Medicare Supplement coverage, suffering from certain chronic diseases or from four or more, were associated with higher spending. Others, such as having a relative live nearby or having dementia, are associated with lower spending. And some, such as having an advance directive, sex, marital status, education, net worth, or religiosity, appeared to have no relationship. Altogether, patient characteristics account for 10% of the variation in spending in the last 6 months of life. Regional factors like end-of-life treatment intensity and number of hospital beds were associated with higher spending and these factors in total were responsible for 5% of the variation. In a combined model, the patient and regional factors continued to be responsible for 15% of the difference in spending, leaving a lot unaccounted for.