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."