Are Regional Variations in End-of-Life Care Intensity Explained by Patient Preferences?

Abstract

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...

Racial and Ethnic Differences in Preferences for End-of-Life Treatment

“…We created simplified survey questions, which may not predict actual treatment choices or receipt. Indeed, in a cross-sectional analysis of these data, higher regional end-oflife expenditures did not predict preferences for more intensive treatment 22 . We did not use decision theoretical approaches such as the standard gamble to ensure all respondents considered the same alternative when offered a choice like mechanical ventilation or drugs for life-prolonging or palliation, nor did we quantify the strength of preferences.…”

“…We also collected information on socio-demographics, health status, social networks, and perceptions of quality and access to health care. See Barnato et al and Fowler et al for detailed description of survey development and cognitive testing 22,23 and Table A1 (available online) for the wording of all survey questions used in the current study.…”

Time for change in culture

“…More cases would help strengthen the authors' conclusions. Interestingly, this qualitative study generates more instructive conclusions about the factors explaining interhospital variability in intensity of care at the end of life than some large quantitative studies, demonstrating the value of qualitative approaches to some questions [8][9][10].…”

Withdrawing Hydration and Feeding in a Person Living in Vegetative State: An Approach from Medical, Anthropological and Ethical Perspectives

“…Let us remember that ignorance is a coercive factor that makes the decisions be weak and infeasible, for they are technically inapplicable, and sometimes contradict the very goals of medicine. [28][29][30][31] Indeed, the more we know the freer and more legitimate our elections are-what proves the fact that human liberty is always executed within concrete, and not hypothetical circumstances. At the end-of-life, legitimacy of decisions is closely associated to its feasibility both technical, and ethical.…”