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Advance Directives Curb Hospital Costs In High-Spending Regions

 |  By cclark@healthleadersmedia.com  
   October 06, 2011

In the last six months of life, patients who lacked treatment-limiting advance directives and lived in areas with the nation's highest healthcare costs generated $5,585 more in Medicare expenditures than patients with prepared documents.

Patients with living wills and/or surrogate medical decision makers who lived in those high-spending regions of the country also were less likely to use hospice services and more likely to die in a hospital than if they had set up those directives.

Having a treatment-limiting advance directive, however, was not associated with differences in aggregate end-of-life spending for decedents in low- and medium-spending regions.

Those are the conclusions of researchers at the University of Michigan, who examined survey data from the Health and Retirement Study, a database sponsored by the National Institute on Aging, Medicare claims information and the National Death Index between 1998 and 2007. In high cost areas of the nation, Medicare spending in the last six months of life was $33,933 if a patient had a treatment-limiting advance directive, but $39,518 if they did not.

"Advance directives are associated with important differences in treatment during the last six months of life for patients who live in areas of high medical expenditures, but not in other regions," wrote Lauren Hersch Nicholas, of the Institute for Social Research at the University of Michigan and colleagues. "This suggests that the clinical effect of advance directives is critically dependent on the context in which a patient receives care."

Their paper is published in the Oct. 5 edition of the Journal of the American Medical Association.

The researchers added that if an additional 6% of decedents in high-use regions of the country had prepared treatment-limiting advance directives, "our estimates suggest that Medicare spending on the 790,061 beneficiaries dying in high-spending hospital referral regions in 2006 would have been $265 million lower."

One surprising finding is that in high Medicare spending areas, those who had advance directives and those who didn't had roughly the same use of aggressive life-sustaining treatments, such as mechanical ventilation, intubation, and parenteral nutrition, at the end of life.

"This may suggest that treatment-limiting advance directives are associated with a quicker withdrawal of these aggressive and expensive interventions, even if the likelihood of initiating these treatments is less strongly affected," Nicholas and colleagues wrote.

The researchers said one interpretation of their finding is that "advance directives are most effective when one prefers treatment that is different from the local norms. Thus, in high-intensity regions, more limited treatment requires an explicit statement."

"We urgently need studies to examine the extent to which greater advance directive use in high-intensity regions would result in treatment that is more concordant with patient preferences and to understand the patient, physician,  and health system characteristics that lead to higher rates of use (of advance directives) in low-spending regions.

Advance directives also were associated with higher adjusted probabilities of hospice use in high-and medium spending regions of the country, but not in lower spending regions, indicating that perhaps practitioners in lower spending regions are culturally less likely to push for, and patients less likely to demand, expensive end of life care.

In a related editorial, Douglas B. White, MD, and Robert M. Arnold, MD, of the University of Pittsburgh, said the results "raise several important questions about the 'mechanisms of action' of advance directives.

"It may be that treatment-limiting advance directives work not by making the decisions, but by giving surrogates and physicians psychological permission to cease life support at some point," they wrote.

Treatment limiting advance directives were associated with savings in high-spending parts of the country but not in low-cost regions, perhaps because in low-spending areas, cultural norms around medical care at the end of life prevail. "In other words, patients tend to die like their neighbors, unless there is a clearly stated preference to the contrary," Arnold and White wrote.

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