Association between physician age and patterns of end-of-life care among older Americans

Abstract

Background: End-of-life (EOL) care patterns may differ by physician age given differences in how physicians are trained or changes associated with aging. We sought to compare patterns of EOL care delivered to older Americans according to physician age.

Methods: We conducted a cross-sectional study of a 20% sample of Medicare fee-for-service beneficiaries aged ≥66 years who died in 2016-2019 (n = 487,293). We attributed beneficiaries to the physician who had >50% of primary care visits during the last 6 months of life. We compared beneficiary-level outcomes by physician age (<40, 40-49, 50-59, or ≥60) in two areas: (1) advance care planning (ACP) and palliative care; and (2) high-intensity care at the EOL.

Results: Beneficiaries attributed to younger physicians had slightly higher proportions of billed ACP (adjusted proportions, 17.1%, 16.1%, 15.5%, and 14.0% for physicians aged <40, 40-49, 50-59, and ≥60, respectively; p-for-trend adjusted for multiple comparisons <0.001) and palliative care counseling or hospice use in the last 180 days of life (64.5%, 63.6%, 61.9%, and 60.8%; p-for-trend <0.001). Similarly, physicians' younger age was associated with slightly lower proportions of emergency department visits (57.4%, 57.0%, 57.4%, and 58.1%; p-for-trend <0.001), hospital admissions (51.2%, 51.1%, 51.4%, and 52.1%; p-for-trend <0.001), intensive care unit admissions (27.8%, 27.9%, 28.2%, and 28.3%; p-for-trend = 0.03), or mechanical ventilation or cardiopulmonary resuscitation (14.2, 14.9%, 15.2%, and 15.3%; p-for-trend <0.001) in the last 30 days of life, and in-hospital death (20.2%, 20.6%, 21.3%, and 21.5%; p-for-trend <0.001).

Conclusions: We found that differences in patterns of EOL care between beneficiaries cared for by younger and older physicians were small, and thus, not clinically meaningful. Future research is warranted to understand the factors that can influence patterns of EOL care provided by physicians, including initial and continuing medical education.

Keywords: advance care planning; end‐of‐life care; palliative care; physician age.

Figure 1.. Flowchart of the study participants

Abbreviation: FFS = fee-for-service.

Figure 2.. Association between physician age and patterns of end-of-life care

Notes. Using decedents 66 years and older from 20% of Medicare claims data 2016–2019, we fit linear regression models adjusted for beneficiaries characteristics (age, gender, race and ethnicity, comorbidities, zip-code level median annual household income, Medicaid coverage, and long-term nursing home resident status) and physician characteristics (gender, geriatric training, health system affiliation, and tertiles of the number of attributed beneficiaries). We also included fixed effects for year of death and Hospital Service Areas in the models. See the main text for the algorithm to attribute each beneficiary’s outcomes to physicians. P-values are adjusted with the Holm-Bonferroni method to account for the multiple comparisons across outcomes (an adjusted p-value of less than 0.05 is considered statistically significant). Abbreviations: CPR = cardiopulmonary resuscitation; ED = emergency department; ICU = intensive care unit.

Figure 3.. Association between physician age and patterns of end-of-life care by condition

Notes. We conducted a subgroup analysis by the following three medical conditions: (1) Alzheimer’s disease-related disorders (ADRD), (2) cancer (breast, colorectal, endometrial, lung, and prostate cancer), and (3) chronic obstructive pulmonary disease (COPD). See the main text and notes for Figure 1 for more details. P-values (for trend) are adjusted with the Holm-Bonferroni method to account for the multiple comparisons across outcomes (an adjusted p-value of less than 0.05 is considered statistically significant). Abbreviations: CPR = cardiopulmonary resuscitation; ED = emergency department; ICU = intensive care unit.

Figure 4.. Association between physician age and patterns of end-of-life care by nursing home status

Notes. We conducted a stratified analysis by long-term nursing home resident status. See the main text and notes for Figure 1 for more details. P-values (for trend) are adjusted with the Holm-Bonferroni method to account for the multiple comparisons across outcomes (an adjusted p-value of less than 0.05 is considered statistically significant and an adjusted p-value greater than 1.00 is winsorized at 1.00). Abbreviations: CPR = cardiopulmonary resuscitation; ED = emergency department; ICU = intensive care unit; NH = nursing home.