Are Regional Variations in End-of-Life Care Intensity Explained by Patient Preferences?: A Study of the US Medicare Population

• Published in: Medical care Vol. 45; no. 5; pp. 386 - 393
• Main Authors: Barnato, Amber E., Herndon, M. Brooke, Anthony, Denise L., Gallagher, Patricia M., Skinner, Jonathan S., Bynum, Julie P. W., Fisher, Elliott S.
• Format: Journal Article
• Language: English
• Published: United States Lippincott Williams & Wilkins 01-05-2007; Lippincott Williams & Wilkins, Inc; Lippincott Williams & Wilkins Ovid Technologies
• Subjects: Aged; Aged, 80 and over; Artificial respiration; Beneficiaries; Centers for Medicare and Medicaid Services (U.S.); Critical Care; Cross-Sectional Studies; Differences; Female; Geography; Health care economics; Health Care Surveys; Health outcomes; Health status; Humans; Male; Medical referrals; Medical treatment; Medicare; Medicare Part A; Medicare Part B; Palliative Care; Patient Satisfaction - statistics & numerical data; Patients; Physicians; Polls & surveys; Practice Patterns, Physicians; Preferences; Regions; Regression analysis; Spending; Sprains and strains; Terminal Care - economics; Terminal Care - organization & administration; United States; United States
• ISSN: 0025-7079; 1537-1948
• DOI: 10.1097/01.mlr.0000255248.79308.41

Objective: We sought to test whether variations across regions in end-of-life (EOL) treatment intensity are associated with regional differences in patient preferences for EOL care. Research Design: Dual-language (English/Spanish) survey conducted March to October 2005, either by mail or computer-assisted telephone questionnaire, among a probability sample of 3480 Medicare part A and/or B eligible beneficiaries in the 20% denominator file, age 65 or older on July 1, 2003. Data collected included demographics, health status, and general preferences for medical care in the event the respondent had a serious illness and less than 1 year to live. EOL concerns and preferences were regressed on hospital referral region EOL spending, a validated measure of treatment intensity. Results: A total of 2515 Medicare beneficiaries completed the survey (65% response rate). In analyses adjusted for age, sex, race/ethnicity, education, financial strain, and health status, there were no differences by spending in concern about getting too little treatment (39.6% in lowest spending quintile, Ql; 41.2% in highest, Q5; P value for trend, 0.637) or too much treatment (44.2% Ql, 45.1% Q5; P = 0.797) at the end of life, preference for spending their last days in a hospital (8.4% Ql, 8.5% Q5; P = 0.965), for potentially life-prolonging drugs that made them feel worse all the time (14.4% Ql, 16.5% Q5; P = 0.326), for palliative drugs, even if they might be life-shortening (77.7% Ql, 73.4% Q5; P = 0.138), for mechanical ventilation if it would extend their life by 1 month (21% Ql, 21.4% Q5; P = 0.870) or by 1 week (12.1% Ql, 11.7%; P = 0.875). Conclusions: Medicare beneficiaries generally prefer treatment focused on palliation rather than life-extension. Differences in preferences are unlikely to explain regional variations in EOL spending.