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The Effect of Advance Planning Directives on End-of-Life Care

By December 16, 2019December 17th, 2019Commentary

Advance planning directives are used by patients to determine what kinds of treatment they receive in certain situations, especially when faced with terminal diseases or conditions.  Medicare has encouraged the elderly to put an advance directive in place.  The goal is to limit the use of intensive, expensive therapies that are likely futile, and to avoid decision-making by surrogates when the patient may be incapacitated by the seriousness of their illness.  A new study in the Journal of the American Medical Association Network Open examines the effects of advance planning directives in the Medicare Advantage setting.    (JAMA Article)   Medicare introduced a code in 2016 to reimburse providers for advance directive discussions with patients, which facilitates research on their effect.  This study looked at the relationship between such discussions (the authors couldn’t observe the actual presence of a directive) and certain kinds of utilization prior to death.  The authors used a large commercial claims database which included Medicare Advantage members and identified those persons with a serious illness and divided them into those who did and did not have an advance directive discussion.  About 5% of the 18,500 people included in the study had an advance planning encounter.  The patients who had advance planning discussions were older, in worse health and had more health utilization and spending in the year before the advance planning session.  Patients who died in the followup period were more likely to have had an advance planning encounter than those who did not.

Persons with an advance planning discussion had more use of hospice and were more likely to have a hospitalization, but they did not have different rates of use of the emergency room.  They were less likely to receive intensive therapies, especially chemotherapy.  Total medical costs were higher for these patients, due to the greater hospital use.  It is possible, even likely, that some of the differences may be attributed to unadjusted-for differences in health status.  It would make sense that the sickest patients, especially those nearing terminal status, would be the most likely to consider use of an advance directive.  One intriguing aspect to this study is that it was done among Medicare Advantage beneficiaries.  Medicare Advantage has become an increasing part of the Medicare program and at least in theory, beneficiaries in that program have more stringent care management and the MA plans are supposed to make an effort to get everyone to have an advance directive, so the results are interesting from that perspective.  But more generally, it would be good to see more research using Medicare Advantage beneficiaries, because so far they are very under-represented in Medicare studies.

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