Advance Care Planning in an Accountable Care Organization Is Associated with Increased Advanced Directive Documentation and Decreased Costs

J Palliat Med. 2018 Apr;21(4):489-502. doi: 10.1089/jpm.2017.0566. Epub 2017 Dec 5.


Background: Advance care planning (ACP) documents patient wishes and increases awareness of palliative care options.

Objective: To study the association of outpatient ACP with advanced directive documentation, utilization, and costs of care.

Design: This was a case-control study of cases with ACP who died matched 1:1 with controls. We used 12 months of data pre-ACP/prematch and predeath. We compared rates of documentation with logit model regression and conducted a difference-in-difference analysis using generalized linear models for utilization and costs.

Setting/subjects: Medicare beneficiaries attributed to a large rural-suburban-small metro multisite accountable care organization from January 2013 to April 2016, with cross reference to ACP facilitator logs to find cases.

Measurements: The presence of advance directive forms was verified by chart review. Cost analysis included all utilization and costs billed to Medicare.

Results: We matched 325 cases and 325 controls (51.1% female and 48.9% male, mean age 81). 320/325 (98.5%) ACP versus 243/325 (74.8%) of controls had a Healthcare Power of Attorney (odds ratio [OR] 21.6, 95% CI 8.6-54.1) and 172/325(52.9%) ACP versus 145/325 (44.6%) controls had Practitioner Orders for Life Sustaining Treatment (OR 1.40, 95% CI 1.02-1.90) post-ACP/postmatch. Adjusted results showed ACP cases had fewer inpatient admissions (-0.37 admissions, 95% CI -0.66 to -0.08), and inpatient days (-3.66 days, 95% CI -6.23 to -1.09), with no differences in hospice, hospice days, skilled nursing facility use, home health use, 30-day readmissions, or emergency department visits. Adjusted costs were $9,500 lower in the ACP group (95% CI -$16,207 to -$2,793).

Conclusions: ACP increases documentation and was associated with a reduction in overall costs driven primarily by a reduction in inpatient utilization. Our data set was limited by small numbers of minorities and cancer patients.

Keywords: advance care planning; advance directives; healthcare costs; healthcare power of attorney; healthcare utilization; practitioner orders for life sustaining treatment.

MeSH terms

  • Accountable Care Organizations / economics
  • Accountable Care Organizations / organization & administration*
  • Advance Care Planning / economics
  • Advance Care Planning / organization & administration*
  • Advance Directives / economics
  • Aged, 80 and over
  • Case-Control Studies
  • Cost Control
  • Documentation / economics*
  • Female
  • Humans
  • Male
  • Medicare / economics
  • United States