Regional Variation in the Association Between Advance Directives and End-of-Life Medicare Expenditures

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Abstract
End-of-life health care is a frequent target for efforts to control Medicare spending. In 2006, treatment for patients in their last year of life accounted for more than one-quarter of Medicare spending.1 Marked geographic variation in Medicare end-of-life spending is well documented,2 and this variation is believed to be driven by physician practice style rather than by differences in patients' preferences for aggressiveness of treatment at the end of life.3 There is concern that this expensive care may have limited clinical effectiveness and may be contrary to what patients want. Surveys report that many patients do not wish to receive aggressive treatment at the end of their lives; however, these preferences are often undocumented.4,5 A national study by Barnato and colleagues6 found that 42% of white Medicare beneficiaries worried about receiving too much care at the end-of-life, whereas an equal proportion worried about receiving too little.