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Original Research |

Determinants of Medical Expenditures in the Last 6 Months of Life

Amy S. Kelley, MD, MSHS; Susan L. Ettner, PhD; R. Sean Morrison, MD; Qingling Du, MS; Neil S. Wenger, MD, MPH; and Catherine A. Sarkisian, MD, MSHS
[+] Article, Author, and Disclosure Information

From Mount Sinai School of Medicine, New York, New York; University of California, Los Angeles, Geffen School of Medicine, Los Angeles, California; James J. Peters Veterans Affairs Medical Center, Bronx, New York; and Veterans Affairs Greater Los Angeles Healthcare System Geriatric Research Education Clinical Center, Los Angeles, California.

Grant Support: By the Brookdale Foundation. Dr. Kelley is a Brookdale Leadership in Aging Fellow. Dr. Morrison is the recipient of a Mid-Career Investigator Award in Patient-Oriented Research (K24 AG022345) from the National Institute on Aging and is supported by the National Palliative Care Research Center. Dr. Sarkisian is supported by the Veterans Affairs Greater Los Angeles Healthcare System Geriatric Research Education Clinical Center.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-1628.

Reproducible Research Statement:Study protocol: Available from Dr. Kelley (e-mail, amy.kelley@mssm.edu). Statistical code: Not available. Data set: Available through the Health and Retirement Study (http://hrsonline.isr.umich.edu), ResDAC (www.resdac.umn.edu/Medicare/requesting_data_NewUse.asp), and The Dartmouth Atlas of Health Care (www.dartmouthatlas.org/).

Requests for Single Reprints: Amy S. Kelley, MD, MSHS, Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1070, New York, NY 10029; e-mail, amy.kelley@mssm.edu.

Current Author Addresses: Drs. Kelley and Morrison and Ms. Du: Mount Sinai School of Medicine, 1 Gustave L. Levy Place, Box 1070, New York, NY 10029.

Drs. Ettner and Wenger: University of California, Los Angeles, 911 Broxton Avenue, Los Angeles, CA 90024.

Dr. Sarkisian: University of California, Los Angeles, Geffen School of Medicine, Department of Medicine, Division of Geriatrics, Veterans Affairs Greater Los Angeles Healthcare System Geriatric Research Education Clinical Center, 10945 Le Conte Avenue, #2339, Los Angeles, CA 90095-1687.

Author Contributions: Conception and design: A.S. Kelley, S.L. Ettner, N.S. Wenger, C.A. Sarkisian.

Analysis and interpretation of the data: A.S. Kelley, S.L. Ettner, R.S. Morrison, Q. Du, N.S. Wenger, C.A. Sarkisian.

Drafting of the article: A.S. Kelley, R.S. Morrison, N.S. Wenger, C.A. Sarkisian.

Critical revision of the article for important intellectual content: A.S. Kelley, S.L. Ettner, R.S. Morrison, Q. Du, N.S. Wenger, C.A. Sarkisian.

Final approval of the article: A.S. Kelley, S.L. Ettner, R.S. Morrison, Q. Du, N.S. Wenger, C.A. Sarkisian.

Statistical expertise: S.L. Ettner, Q. Du.

Obtaining of funding: A.S. Kelley, C.A. Sarkisian.

Administrative, technical, or logistic support: R.S. Morrison, Q. Du, N.S. Wenger.

Collection and assembly of data: Q. Du.

Ann Intern Med. 2011;154(4):235-242. doi:10.7326/0003-4819-154-4-201102150-00004
Text Size: A A A

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.

Design: 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.

Setting: United States, 2000 to 2006.

Participants: 2394 Health and Retirement Study decedents aged 65.5 years or older.

Measurements: 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.

Limitation: The study limitations include the decedent sample, proxy informants, and a large proportion of unexplained variation.

Conclusion: 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.

Primary Funding Source: The Brookdale Foundation.


Grahic Jump Location
Appendix Figure.
Study flow diagram.

The sampling frame encompassed deaths over 6 years and includes data spanning 6 years of HRS interviews. For each participant, data from a single core and single exit interview were used: core 2000 + exit 2002; core 2002 + exit 2004; core 2004 + exit 2006. HRS = Health and Retirement Study.

Grahic Jump Location




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Surrogate Burden and End of life Decision Making
Posted on February 15, 2011
Jeffrey T. Berger
Winthrop University Hospital
Conflict of Interest: None Declared

The study by Kelley, et al. provides important insights into end of life care. Their findings about the lack of impact of advance directives on treatment are consistent with other studies. While a number of factors are operative here, an under recognized one is the significant stress under which surrogates frequently operate. These include managing their own anticipatory grief, considering their own emotional and other burdens, and deliberating within a group or family dynamic (1-4). Greater attention to supporting surrogates in their role through more regular employment of resources and expertise such as social work, pastoral care, palliative care, may hold a key to better end of life decision making.


1. Braun UK, Beyth RJ, Ford ME, McCullough LB. Voices of African American, Caucasian, and Hispanic surrogates on the burdens of end-of-life decision making. J Gen Intern Med 2008 Mar;23(3):267-74.

2. Vig EK, Starks H, Taylor JS, Hopley EK, Fryer-Edwards K. Surviving surrogate decision-making: what helps and hampers the experience of making medical decisions for others. J Gen Intern Med 2007 Sep;22(9):1274-9.

3. Rid A, Wendler D. Can we improve treatment decision-making for incapacitated patients? Hastings Cent Rep. 2010;40(5):36-45.

4. Berger JT. Patients' Concerns for Family Burden: A Nonconforming Preference in Standards for Surrogate Decision Making. J Clinic Ethic, 2009:20(2):158-161.

Conflict of Interest:

None declared

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