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. Previous studies have shown that regions with greater overall EOL spending do not have better outcomes; mortality, quality of care, and patient satisfaction among cohorts of patients with common serious conditions are sometimes worse, 2,3 as are perceptions of the quality of EOL care among bereaved family members. 4 In contrast, higher spending regions do have a greater regional supply of specialists, 5 hospital and ICU beds, 6-9 and other technologies. 10,11 Physicians who practice in high-intensity regions have a greater tendency to recommend tests, referrals, and treatments for patients described in structured vignettes and are less likely to refer to hospice. 12,13 It is unknown whether these differences in supply and physician practice style reflect differences in preferences for treatment among patients who reside in these highspending regions. Yet, the policy prescriptions for addressing these regional variations depend critically on whether they are the consequence of differences across regions in patient preferences, the consequence of physician "enthusiasm" or "supplier-induced demand," or other factors related to the supply of health care capacity. 14-16We sought to determine whether EOL tr...

Regional variation in health care use may stem, in part, from the fact that patients in high-utilization regions demand and receive more-intensive care. We examine the association between patients’ care-seeking preferences and use of services, using a national survey of Medicare patients. Patients’ preferences, in addition to health and socio-demographic characteristics, are associated with differences in individuals’ use of office visits. However, we find that patients’ preferences for seeking primary and specialty medical care do not play a significant role in explaining regional variation in health care use.

ABSTRACT:The National Osteoporosis Foundation and American College of ObstetricsGynecology have expanded osteoporosis therapy recommendations by changing the treatment threshold. We determined the impact of this recommendation using nationally representative U.S. data. The new threshold changes the number of women for whom treatment is recommended from 6.4 million to 10.8 million among women age sixty-five and older (at a net cost of at least $28 billion) and from 1.6 million to 4.0 million among women ages 50-64 (at a net cost of at least $18 billion). Whether or not offering treatment to these additional women will reduce the number of hip fractures is unknown. [Health Affairs 26, no. 6 (2007): 1702-1711 10.1377/hlthaff.26.6.1702 T r a d i t i o n a l ly, a d i s e a s e was something a patient experienced directly (and typically suffered from). Increasingly, diseases are being defined more broadly. For example, conditions that have historically been considered risk factors for diseases such as heart attack, stroke, and diabetes are now being treated as diseases in their own right. Examples include high cholesterol (hyperlipidemia), hypertension, glucose intolerance, and osteoporosis. 1 Broadening disease definitions can have major implications. Some patients may benefit from treatment that they would not otherwise have received. But broadening disease definitions also means that more people become patients. Simply labeling people as diseased leads to worry and has been shown to make people feel and act sick. 2 Also, as more patients are diagnosed, more are treated, thus exposing them to the potential harms of treatment. Finally, as the number of patients grows, spending rises.Osteoporosis is a prime example of the broadening of a disease definition. Prior to the 1990s, osteoporosis was a clinical diagnosis reserved for patients experiencing painful fractures (most commonly vertebral) not associated with major trauma. Since 1994, the definition (promulgated by the World Health Organization, or WHO) combines patients H e a l t h T r a c k i n g

CONTEXT: Unnecessary exposure to medical interventions can harm patients. Many hope that generalist physicians can limit such unnecessary exposure.OBJECTIVE: To assess older Americans' perceptions of the need for tests and referrals that their personal physician deemed unnecessary. DESIGN:Telephone survey with mail follow-up in English and Spanish, conducted from May to September 2005 (overall response rate 62%).STUDY PARTICIPANTS: Nationally representative sample of 2,847 community-dwelling Medicare beneficiaries. Main analyses focus on the 2,319 who had a personal doctor ("one you would see for a check-up or advice if you were sick") whom they described as a generalist ("doctor who treats many different kinds of problems").MAIN OUTCOME MEASURE: Proportion of respondents wanting a test or referral that their generalist suggested was not necessary using 2 clinical vignettes (cough persisting 1 week after other flu symptoms; mild but definite chest pain lasting 1 week).RESULTS: Eighty-two percent of Medicare beneficiaries had a generalist physician; almost all (97%) saw their generalist at least once in the past year. Among those with a generalist, 79% believed that it is "better for a patient to have one general doctor who manages most of their medical problems" than to have each problem cared for by a specialist. Nevertheless, when faced with new symptoms, many would want tests and referrals that their doctor did not think necessary. For a cough persisting 1 week after flu symptoms, 34% would want to see a lung specialist even if their generalist told them they "probably did not need to see a specialist but could if they wanted to." For 1 week of mild but definite chest pain when walking up stairs, 55% would want to see a heart specialist even if their generalist did not think it necessary. In these same scenarios, even higher proportions would want diagnostic testing; 57% would want a chest x-ray for the cough, and 74% would want "special tests" for the chest pain.CONCLUSIONS: When faced with new symptoms, many older patients report that they would want a diagnostic test or specialty referral that their generalist thought was unnecessary. Generalists striving to provide patient-centered care while at the same time limiting exposure to unnecessary medical interventions will need to address their patients' perceptions regarding the need for these services.KEY WORDS: geriatrics; patient perceptions; tests and referrals; shared decision making.

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