• Nancy L Keating, Haiden A Huskamp, Elena Kouri, Deborah Schrag, Mark C Hornbrook, David A Haggstrom, and Mary Beth Landrum.
• Nancy L. Keating ( keating@hcp.med.harvard.edu ) 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.
• Health Aff (Millwood). 2018 Jul 1; 37 (7): 1136-1143.

AbstractHealth 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.

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