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J Palliat Med. 2018 Jan;21(1):44-54. doi: 10.1089/jpm.2017.0063. Epub 2017 Aug 3.

Prospective Identification of Patients at Risk for Unwarranted Variation in Treatment.

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1 Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, New York.
2 Geriatric Research Education and Clinical Centers, James J Peters VA Medical Center , Bronx, New York.
3 Division of Geriatrics, Department of Medicine, University of California , San Francisco, San Francisco, California.
4 Department of Economics, Dartmouth College, The Dartmouth Institute for Health Policy and Clinical Practice , Dartmouth Geisel School of Medicine, Lebanon , New Hampshire.



Understanding factors associated with treatment intensity may help ensure higher value healthcare.


To investigate factors associated with Medicare costs among prospectively identified, seriously ill older adults and examine if baseline prognosis influences the impact of these factors.


Prospective observation of Health and Retirement Study cohort with linked Medicare claims.


We identified people with incident serious illness (a serious medical condition, for example, metastatic cancer or functional impairment); calculated subjects' one-year mortality risk; and then followed them for one year. We examined relationships between individual and regional characteristics and total Medicare costs, and then stratified analyses by one-year mortality risk: low, moderate, and high.


From 2002 to 2012, 5208 subjects had incident serious illness: mean age 78 years, 60% women, 76% non-Hispanic white, and 39% hospitalized in the past year. During one-year follow-up, 12% died. Total Medicare costs averaged $20,607. In multivariable analyses, indicators of poor health (e.g., cancer, advanced heart and lung disease, multimorbidity, functional impairment, and others) were significantly associated with higher costs (pā€‰<ā€‰0.05). However, among those with high mortality risk, health-related variables were not significant. Instead, African American race (rate ratio [RR] 1.56) and moderate-to-high spending regions (RR 1.31 and 1.54, respectively) were significantly associated with higher costs. For this high-risk population, residence in high-spending regions was associated with $31,476 greater costs among African Americans, and $11,162 among other racial groups, holding health constant.


Among seriously ill older adults, indicators of poor health are associated with higher costs. Yet, among those with poorest prognoses, nonmedical characteristics-race and regional practice patterns-have greater influence on treatment. This suggests there may be novel opportunities to improve care quality and value by assuring patient-centered, goal-directed care.


Medicare; disparities; health services research

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