Are regional variations in end-of-life care intensity explained by patient preferences?: A Study of the US Medicare Population

Abstract

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, Q1; 41.2% in highest, Q5; P value for trend, 0.637) or too much treatment (44.2% Q1, 45.1% Q5; P = 0.797) at the end of life, preference for spending their last days in a hospital (8.4% Q1, 8.5% Q5; P = 0.965), for potentially life-prolonging drugs that made them feel worse all the time (14.4% Q1, 16.5% Q5; P = 0.326), for palliative drugs, even if they might be life-shortening (77.7% Q1, 73.4% Q5; P = 0.138), for mechanical ventilation if it would extend their life by 1 month (21% Q1, 21.4% Q5; P = 0.870) or by 1 week (12.1% Q1, 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.

FIGURE 1

Intensity of acute medical services provided to Medicare enrollees in the last 6 months of life, by hospital referral region (2000–2003). HRRs are color-coded by the mean per-capita Medicare spending in dollars on hospital and physician services among fee-for-service beneficiaries in their last 6 months of life who reside in the HRR. Thirty-four HRRs contributed to the highest qunitile of spending (depicted in black) and 88 HRRs contributed to the lowest quintile (depicted in lightest gray). There were no study respondents from 16 of 306 total HRRs (depicted in white).

FIGURE 2

Proportion of beneficiaries living in regions with differing levels of EOL spending reporting particular EOL treatment concerns and preferences. Crude (left panel) and adjusted (right panel) results are presented. Responses are summarized by quintile of EOL spending, but P values are drawn from models with hospital referral region-level EOL spending entered as a continuous dollar figure, not a categorical variable. *Adjusted for age, sex, race/ethnicity, education, financial strain, and health status. MV indicates mechanical ventilation.