What Do They Want Now? Contacts Between Hospice and Family in the Last Week of Life (417-C)

Abstract

Objectives 1. Recognize the wide variation in Medicare expenditures in the last 6 months of life. 2. Identify patient and region characteristics that are associated with the variation. Background. Medical expenditures at the end of life vary substantially and vastly exceed costs during other periods. Such spending is unsustainable as the population ages. Research objectives. (1) Identify and examine patient-level determinants of Medicare expenditures in the last 6 months of life. (2) Determine the contribution of these factors to the overall variation in expenditures while accounting for regional characteristics. Methods. Using longitudinal data from the nationally representative Health and Retirement Study, Medicare claims, and the Dartmouth Atlas of Health Care, we constructed regression models to investigate the relationship between total Medicare expenditures in the last 6 months of life and (1) patient characteristics, (2) regional characteristics, and (3) both patient and regional characteristics. Results. Several patient characteristics, including decline in functional status (rate ratio 1.64, p < 0.001), Hispanic ethnicity (1.47, p < 0.001), African American race (1.45, p < 0.001), and chronic disease such as diabetes (1.16, p< 0.001), are associated with higher Medicare expenditures. Availability of a nearby relative (0.90, p 1⁄4 0.01) and dementia diagnosis (0.78, p < 0.001) were associated with lower expenditures. Regional resources, includingmorehospitals bedsper capita (1.02, p< 0.001), were associated with higher expenditures. Patient characteristics explained 12% of overall variance and retained statistically significant relationships with expenditures after controlling for regional characteristics. Conclusion. Patient characteristics, including functional decline, race/ethnicity, chronic disease, and nearby family, are important determinants of Medicare expenditures at the end of life, independent of regional characteristics. Implications for research, policy, or practice. Further research is needed to determine when and if high-cost, life-sustaining treatment is consistent with patient preferences or indicative of inappropriate, poor quality medical care. Interventions and policies designed to decrease inappropriate expenditures and patient suffering at the end of life must address both regional and patient-centered sources of variation. Domain All domains