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Health Aff (Millwood). 2018 Jul;37(7):1136-1143. doi: 10.1377/hlthaff.2018.0015.

Factors Contributing To Geographic Variation In End-Of-Life Expenditures For Cancer Patients.

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Nancy L. Keating ( ) is a professor of health care policy and medicine in the Department of Health Care Policy, Harvard Medical School and the Division of General Internal Medicine at Brigham and Women's Hospital, both in Boston, Massachusetts.
Haiden A. Huskamp is the 30th Anniversary Professor of Health Care Policy in the Department of Health Care Policy, Harvard Medical School.
Elena Kouri is project director in the Department of Health Care Policy at Harvard Medical School.
Deborah Schrag is a professor of medicine at Harvard Medical School and a research scientist in medical oncology and population sciences at the Dana-Farber Cancer Institute, in Boston.
Mark C. Hornbrook is a senior investigator emeritus in the Center for Health Research, Kaiser Permanente Northwest, in Portland, Oregon.
David A. Haggstrom is an associate professor of medicine at Indiana University School of Medicine and core investigator at the Indianapolis Veterans Affairs Medical Center, in Indianapolis.
Mary Beth Landrum is a professor of health care policy in the Department of Health Care Policy, Harvard Medical School.


Health care spending in the months before death varies across geographic areas but is not associated with outcomes. Using data from the prospective multiregional Cancer Care Outcomes Research and Surveillance Consortium (CanCORS) study, we assessed the extent to which such variation is explained by differences in patients' sociodemographic factors, clinical factors, and beliefs; physicians' beliefs; and the availability of services. Among 1,132 patients ages sixty-five and older who were diagnosed with lung or colorectal cancer in 2003-05, had advanced-stage cancer, died before 2013, and were enrolled in fee-for-service Medicare, mean expenditures in the last month of life were $13,663. Physicians in higher-spending areas reported less knowledge about and comfort with treating dying patients and less positive attitudes about hospice, compared to those in lower-spending areas. Higher-spending areas also had more physicians and fewer primary care providers and hospices in proportion to their total population than lower-spending areas did. Availability of services and physicians' beliefs, but not patients' beliefs, were important in explaining geographic variations in end-of-life spending. Enhanced training to better equip physicians to care for patients at the end of life and strategic resource allocation may have potential for decreasing unwarranted variation in care.


Health Spending; Variations

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