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

Study Questions:

What is the relationship between treatment-limiting advance directive use, end-of-life Medicare expenditures, and use of palliative and intensive treatments?


The authors prospectively collected survey data from the Health and Retirement Study for 3,302 Medicare beneficiaries who died between 1998 and 2007, and linked to Medicare claims and the National Death Index. Multivariable regression models examined associations between advance directives, end-of-life Medicare expenditures, and treatments by level of Medicare spending in the decedent’s hospital referral region.


Advance directives specifying limits in care were associated with lower spending in hospital referral regions with high average levels of end-of-life expenditures (−$5,585 per decedent; 95% CI, −$10,903 to −$267), but there was no difference in spending in hospital referral regions with low or medium levels of end-of-life expenditures. Directives were associated with lower adjusted probabilities of in-hospital death in high- and medium-spending regions; −9.8% in high-spending regions and −5.3% in medium-spending regions. Advance directives were associated with higher adjusted probabilities of hospice use in high- and medium-spending regions; 17% in high-spending regions and 11% in medium-spending regions, but not in low-spending regions. The differences in end-of-life spending across regions and advance directive status were concentrated among the 72% experiencing at least one hospitalization in the last 6 months of life. There was no evidence of heterogeneity of the advance directive effect in high-spending region by cause of death. When compared to those requesting limited care, decedents who requested all efforts to extend their life used $8,060 more care at the end-of life.


The authors concluded 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.


The data provide important estimates of cost savings with an increase in use of advanced directives. The authors estimated that if an additional 6% of decedents in high-intensity regions had treatment-limiting advance directives in place, Medicare spending on the 790,061 beneficiaries dying in high spending hospital referral regions in 2006 would have been $265 million lower. My clinical experience is that too few persons at high risk for death based upon age, heart disease, and cancer have advanced directives, or knowledge and plans for how and when to consult hospice programs.

Keywords: Advance Directives, Hospices, Cost Savings, Medicare

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