title: Determinants of medical expenditures in the last 6 months of life.
abstract: BACKGROUND
  End-of-life medical expenditures exceed costs of care during other years, vary across regions, and are likely to be unsustainable. Identifying determinants of expenditure variation may reveal opportunities for reducing costs.
  
  
  OBJECTIVE
  To identify patient-level determinants of Medicare expenditures at the end of life and to determine the contributions of these factors to expenditure variation while accounting for regional characteristics. It was hypothesized that race or ethnicity, social support, and functional status are independently associated with treatment intensity and controlling for regional characteristics, and that individual characteristics account for a substantial proportion of expenditure variation.
  
  
  METHODS
  Using data from the Health and Retirement Study, Medicare claims, and The Dartmouth Atlas of Health Care, relationships were modeled between expenditures and patient and regional characteristics.
  
  
  METHODS
  United States, 2000 to 2006.
  
  
  METHODS
  2394 Health and Retirement Study decedents aged 65.5 years or older.
  
  
  METHODS
  Medicare expenditures in the last 6 months of life were estimated in a series of 2-level multivariable regression models that included patient, regional, and patient and regional characteristics.
  
  
  RESULTS
  Decline in function (rate ratio [RR], 1.64 [95% CI, 1.46 to 1.83]); Hispanic ethnicity (RR, 1.50 [CI, 1.22 to 1.85]); black race (RR, 1.43 [CI, 1.25 to 1.64]); and certain chronic diseases, including diabetes (RR, 1.16 [CI, 1.06 to 1.27]), were associated with higher expenditures. Nearby family (RR, 0.90 [CI, 0.82 to 0.98]) and dementia (RR, 0.78 CI, 0.71 to 0.87]) were associated with lower expenditures, and advance care planning had no association. Regional characteristics, including end-of-life practice patterns (RR, 1.09 [CI, 1.06 to 1.14]) and hospital beds per capita (RR, 1.01 [CI, 1.00 to 1.02]), were associated with higher expenditures. Patient characteristics explained 10% of overall variance and retained statistically significant relationships with expenditures after regional characteristics were controlled for.
  
  
  CONCLUSIONS
  The study limitations include the decedent sample, proxy informants, and a large proportion of unexplained variation.
  
  
  CONCLUSIONS
  Patient characteristics, such as functional decline, race or ethnicity, chronic disease, and nearby family, are important determinants of expenditures at the end of life, independent of regional characteristics.
  
  
  BACKGROUND
  The Brookdale Foundation.
authors.affiliation: Mount Sinai School of Medicine, New York, New York 10029, USA. amy.kelley@mssm.edu
authors.forename: Amy S
authors.initials: AS
authors.lastname: Kelley
authors.forename: Susan L
authors.initials: SL
authors.lastname: Ettner
authors.forename: R Sean
authors.initials: RS
authors.lastname: Morrison
authors.forename: Qingling
authors.initials: Q
authors.lastname: Du
authors.forename: Neil S
authors.initials: NS
authors.lastname: Wenger
authors.forename: Catherine A
authors.initials: CA
authors.lastname: Sarkisian
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002908:Chronic Disease / Q000191:economics; D005006:Ethnicity; D005260:Female; D005102:Health Expenditures; D006801:Humans; D007182:Income; D057187:Independent Living; D008297:Male; D006278:Medicare / Q000191:economics*; D012044:Regression Analysis; D012944:Social Support; D012959:Socioeconomic Factors; D013727:Terminal Care / Q000191:economics*; D014481:United States