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Are Regional Variations in End-of-Life Care Intensity Explained by Patient Preferences?: A Study of the US Medicare Population

Barnato, Amber E. MD, MPH, MS*; Herndon, M Brooke MD; Anthony, Denise L. PhD; Gallagher, Patricia M. PhD§; Skinner, Jonathan S. PhD; Bynum, Julie P. W. MD, MS; Fisher, Elliott S. MD, MPH¶∥

doi: 10.1097/01.mlr.0000255248.79308.41
Original Article

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.

From the *Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania; †Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; ‡Department of Sociology, Dartmouth College, Hanover, New Hampshire; §Center for Survey Research, University of Massachusetts, Boston, Massachusetts; ¶Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, New Hampshire; and ∥VA Outcomes Group, White River Junction, Vermont.

Supported by National Institute on Aging (NIA) grant PO1 AG19783. Dr. Barnato was supported by NIA career-development grant K08 AG021921.

Presented at the Society of General Internal Medicine Annual Meeting in Los Angeles, CA on April 28, 2006.

Reprints: Amber E. Barnato, MD, MPH, MS, University of Pittsburgh, Center for Research on Health Care, 200 Meyran Avenue, Suite 200, Pittsburgh PA 15312. E-mail:

© 2007 Lippincott Williams & Wilkins, Inc.