title: Rural-Urban Differences in Costs of End-of-Life Care for Elderly Cancer Patients in the United States.
abstract: The objective of this study was to examine the rural-urban differences in Medicare expenditures on end-of-life care for elderly cancer patients in the United States.
  
  
  
  We analyzed Medicare claims data for 175,181 elderly adults with lung, colorectal, female breast, or prostate cancer diagnosis who died in 2008. The end-of-life costs were quantified as total Medicare expenditures for the last 12 months of care including inpatient, outpatient, physician services, hospice, home health, skilled nursing facilities (SNF), and durable medical expenditure. Linear regression models were used to estimate rural-urban differences in log-transformed end-of-life costs and logistic regressions were used to estimate probability of service use, adjusting for demographics, socioeconomic status, and comorbidities.
  
  
  
  On average, elderly cancer patients cost Medicare $51,273, $50,274, $62,815, and $50,941 in the last year for breast, prostate, colorectal, and lung cancer, respectively. Rural patients cost Medicare about 10%, 6%, 8%, and 4% less on end-of-life care than their urban counterparts for breast, prostate, colorectal, and lung cancer, respectively. Rural cancer patients were less likely to use hospice and home health, more likely to use outpatient and SNF, and they cost Medicare less on inpatient and physician services and more on outpatient care conditional on service use.
  
  
  
  The lower Medicare spending on end-of-life care for the rural cancer patients suggests disparities based on place of residence. A future study that delineates the source of the rural-urban difference can help us understand whether it indicates inappropriate level of palliative care and find effective policies to reduce the urban-rural disparities.
authors.affiliation: Department of Health Services Research and Administration, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska. hongmeiwang@unmc.edu.
authors.forename: Hongmei
authors.initials: H
authors.lastname: Wang
authors.affiliation: Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska.
authors.forename: Fang
authors.initials: F
authors.lastname: Qiu
authors.affiliation: Center for Collaboration on Research Design and Analysis, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska.
authors.forename: Eugene
authors.initials: E
authors.lastname: Boilesen
authors.affiliation: Department of Health Services Research and Administration, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska.
authors.forename: Preethy
authors.initials: P
authors.lastname: Nayar
authors.affiliation: Department of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska.
authors.forename: Lina
authors.initials: L
authors.lastname: Lander
authors.affiliation: El Paso County Public Health, Communicable Disease Program, Colorado Springs, Colorado.
authors.forename: Kate
authors.initials: K
authors.lastname: Watkins
authors.affiliation: Department of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska.
authors.forename: Shinobu
authors.initials: S
authors.lastname: Watanabe-Galloway
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005102:Health Expenditures / Q000706:statistics & numerical data; D006801:Humans; D016015:Logistic Models; D008297:Male; D006278:Medicare / Q000191:economics / Q000706:statistics & numerical data*; D009369:Neoplasms / Q000628:therapy*; D012424:Rural Population / Q000706:statistics & numerical data*; D013727:Terminal Care / Q000191:economics* / Q000706:statistics & numerical data; D014481:United States; D014505:Urban Population / Q000706:statistics & numerical data*
keywords: Medicare; cancer; end-of-life care; medical expenditure; rural-urban differences