Physician Preferences for Aggressive Treatment at the End of Life and Area-Level Health Care Spending: The Johns Hopkins Precursors Study

Objective: To determine whether physician preferences for end-of-life care were associated with variation in health care spending. Method: We studied 737 physicians who completed the life-sustaining treatment questionnaire in 1999 and were linked to end-of-life care data for the years 1999 to 2009 from Medicare-eligible beneficiaries from the Dartmouth Atlas of Health Care (in hospital-related regions [HRRs]). Using latent class analysis to group physician preferences for end-of-life treatment into most, intermediate, and least aggressive categories, we examined how physician preferences were associated with health care spending over a 7-year period. Results: When all HRRs in the nation were arrayed in quartiles by spending, the prevalence of study physicians who preferred aggressive end-of-life care was greater in the highest spending HRRs. The mean area-level intensive care unit charges per patient were estimated to be US$1,595 higher in the last 6 months of life and US$657 higher during the hospitalization in which death occurred for physicians who preferred the most aggressive treatment at the end of life, when compared with average spending. Conclusions: Physician preference for aggressive end-of-life care was correlated with area-level spending in the last 6 months of life. Policy measures intended to minimize geographic variation in health care spending should incorporate physician preferences and style.