Advance directives do have an impact on health care at the end of life, especially in regions of the country with high spending on end-of-life care, according to a U-M study.
People who had completed advance directives stating their preferences for care were less likely to die in a hospital and more likely to receive palliative hospice care than similar decedents without advance directives.
“Advance directives may help patients get the care they want if they prefer less aggressive care at the end of life, while also providing cost savings to the Medicare program, particularly in higher-spending regions of the country,” says Lauren Hersch Nicholas, a U-M health economist who is the lead author of the study.
The study is in the Oct. 5 issue of the Journal of the American Medical Association.
“Accompanying greater use of palliative care, we found that Medicare expenditures for those with advance directives were significantly lower than for those without, but only in those regions that spent more than average per person on end-of-life care,” she says. In contrast, advance directives seemed to have little effect on care received by people living in regions of the country that have lower levels of medical spending at the end of life.
The study, which is among the first to have national data linking end-of-life spending, treatments, and patients’ advance directives, is based on a sample of 3,302 Medicare beneficiaries from the Health and Retirement Study, a nationally representative longitudinal study of more than 30,000 older Americans conducted by the Institute for Social Research (ISR). The study is funded by the National Institute on Aging (NIA), part of the National Institutes of Health, and by the Social Security Administration.
The U-M research team analyzed data on Health and Retirement Study participants who died between 1998 and 2007. Their records were linked to Medicare claims and the National Death Index. The study conducted interviews with next-of-kin after the survey respondent’s death, during which they asked about the decedent’s end-of-life experience, including the nature and type of their advance directives.
“The unique design of the Health and Retirement Study makes it the ideal vehicle for this type of analysis,” says Richard Suzman, director of the NIA’s Division of Behavioral and Social Research, which has funded the study for more than 20 years. “The combination of individual interviews and links to administrative data such as Medicare provides a rich data resource that can be used for analyses. Moving forward, we expect the study will be used to more fully explore quality-of-life issues at the end of life.”
“The most exciting thing about this study is that it provides some clear advice for real people, the kind of people who give of their time to participate in research,” says David Weir, an economist and research professor at ISR, the senior author of the paper and director of the Health and Retirement Study. “If you care about what may happen to you in your final days, take some time to complete an advance directive, and talk it over with those closest to you. It can make a big difference.”
Discussing and documenting the type of care that you want at the end of life — either with your family or your physician — can be stressful and difficult, says author Theodore Iwashyna. “But our study suggests these discussions may be very important for getting the type of end-of-life care you want, especially if you live in a region of the country where more aggressive care is the norm.”
Co-authors of the study are Kenneth Langa, and Iwashyna, both affiliated with the Medical School, the Ann Arbor Veterans Affairs Health System and ISR.
