Advance Directives Linked to Regional Medical Expenditures

High-spending areas have lower end-of-life costs, in-hospital death, and increased hospice care

TUESDAY, Oct. 4 (HealthDay News) -- Advance directives (living wills) specifying limitations in end-of-life care are associated with significantly lower levels of Medicare spending, lower likelihood of in-hospital death, and higher use of hospice care during the last six months of life for patients living in regions with high medical expenditures but not in other regions, according to a study published in the Oct. 5 issue of the Journal of the American Medical Association.

Lauren Hersch Nicholas, Ph.D., M.P.P., from the University of Michigan in Ann Arbor, and colleagues investigated the regional variations in the correlations between treatment-limiting advance-directive use, end-of-life Medicare expenditures, and use of palliative and intensive treatments in 3,302 Medicare beneficiaries who died between 1998 and 2007. Medicare expenditures, life-sustaining treatments, hospice care, and in-hospital death over the last six months of life were the main outcome measures.

The investigators found that, in hospital referral regions with high average end-of-life expenditures, advance directives specifying limits in care correlated with reduced spending. Hospital referral regions with low or medium levels of end-of life expenditures showed no difference in spending. In high- and medium-spending regions, directives correlated with lower adjusted probabilities of in-hospital death. Advance directives correlated with higher adjusted probabilities of hospice use in high- and medium-spending regions, but not in low-spending regions.

"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," the authors write.

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