Regional variation in the association between advance directives and end-of-life Medicare expenditures

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.

Figure 1

Geographic Variation in Advance Directives^{a,b a}Unadjusted proportion of decedents with written advance directives across hospital referral regions in the United States. 3,302 Health and Retirement Study decedents dying between 1998 and 2007; 454 lived in low-spending regions, 1,847 in medium-spending regions, 1,001 in high-spending regions. Spending levels for Regions are based on average per-decedent Medicare spending in the last 6 months life reported by the Dartmouth Atlas of Health Care for 1999 –2005, not on the particular decedents in the present study. ^bAny Advance Directive includes those with a Living Will or a Durable Power of Attorney for Healthcare (DPOA). Treatment-Limiting Directive includes those with a Living Will that specifies “a desire to limit care in certain situations.”