Nancy L. Keating (
Haiden A. Huskamp is the 30th Anniversary Professor of Health Care Policy in the Department of Health Care Policy, Harvard Medical School.
Health Aff (Millwood). 2018 Jul;37(7):1136-1143. doi: 10.1377/hlthaff.2018.0015.
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.
在死亡前的几个月里，医疗保健支出在地理区域之间存在差异，但与结果无关。利用前瞻性多区域癌症护理结果研究和监测联盟（CanCORS）研究的数据，我们评估了这种差异在多大程度上可以用患者的社会人口统计学因素、临床因素和信念、医生的信念以及服务的可及性来解释。在 2003-05 年间被诊断患有肺癌或结直肠癌、患有晚期癌症、2013 年前死亡且参加按服务收费的医疗保险的 1132 名 65 岁及以上的患者中，在生命的最后一个月，平均支出为 13663 美元。与低支出地区相比，高支出地区的医生对治疗临终患者的知识和舒适度较低，对临终关怀的态度也较消极。与低支出地区相比，高支出地区的医生比例更高，而初级保健提供者和临终关怀机构的比例更低。服务的可及性和医生的信念，但不是患者的信念，是解释临终关怀支出地理差异的重要因素。加强对医生的培训，使他们更好地为临终患者提供护理，以及战略性的资源配置，可能有潜力减少不必要的护理差异。
