Regional Variation in the Association Between Advance Directives and End-of-Life Medicare Expenditures

This study examined regional variation in the associations between treatment-limiting advance directive use, end-of-life Medicare expenditures, and use of palliative and intensive treatments. Researchers used prospectively collected survey data from the Health and Retirement Study for 3,302 Medicare beneficiaries who died between 1998 and 2007, linked to Medicare claims and the National Death Index. Results indicate that 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. Specifically, (1) advance directives specifying limits in care were associated with lower spending in hospital referral regions with high average levels of end-of-life expenditures, but there was no difference in spending in hospital referral regions with low or medium levels of end-of-life expenditures; (2) directives were associated with lower adjusted probabilities of in-hospital death in high- and medium-spending regions; and (3) directives were associated with higher adjusted probabilities of hospice use in high- and medium-spending regions, but not in low-spending regions.