Advance Directive Completion and Hospital Out-of-Pocket Expenditures

Abstract Healthcare costs remain high at end of life. Although advance directives (AD) have been shown to improve care congruence with patients’ preferences and lower cost of healthcare services, little is known about the relationship between AD completion and hospital out-of-pocket costs. This study examined whether AD completion was associated with lower hospital out-of-pocket spending at end of life. We used the Health and Retirement Study participants who died between 2000 and 2014 (N=9,228) to examine the association through the use of a two-part analytic model that has been widely used in health economics. We controlled for socioeconomic status, death-related characteristics, and health insurance coverage and imputed missing data using multiple imputation by chained equations. Of the 43.9% of decedents who completed an AD, 90.7% chose to limit care or to be kept comfortable; 78.8% indicated that they wanted to withhold treatment, and 5.6% wanted to prolong life. Having an AD was significantly associated with $632 (95% CI: [-$1,116.47, -$146.71]) lower hospital out-of-pocket costs, with greater savings among younger decedents, dropping from $1,560 (95% CI: [-$2,652, -$268]) at age 50 to $230 (95% CI: [-$445, -$14]) at age 110. Decedents who completed an AD 12 months or less before death had higher out-of-pocket spending ($1,591 on average) than those who completed more than a year before death ($1,001 on average). Our findings have policy implications for physician-patient communication about costs of care and may provide an opportunity for physicians to involve cost-sharing discussions when completing ADs with patients.

Results: The Cronbach's Alpha for the LOS was a = 0.76 and the LOS variables primarily loaded onto a single component demonstrating undimensionality.The LOS significantly predicted self-reported health (□= .16;p < .001)with higher lost work associated with negative health outcomes (Cox and Snell R2 = 0.07).The LOS score significantly predicted mental health declines (□ = .07;p = .002)(Coxand Snell R2 = 0.07).
Discussion: Population-level data indicates that health declines following both unemployment and retirement, but there is ample evidence that early or planned retirements do not show the same negative health impacts.We examined the health impact of retirement using the construct of lost work opportunity rather than voluntary or involuntary retirement, per se.Our findings indicate that as much as 7% of negative health changes in the early retirement years could be attributable to employment changes that were unplanned or experienced as outside the retiree's control.Employee turnover is a huge concern for nursing homes that care for millions of older individuals whose physical and cognitive impairments make them vulnerable, especially in the middle of a pandemic like COVID-19.Existing research has shown that high turnover of employees can lead to poorer quality of care.Low pay is often cited as one of the key reasons for high turnover of employees in nursing homes.For-profit nursing homes may try to maximize profits by limiting wages paid to their employees.In this study, we examine whether profit-status of a facility is associated with high turnover of its employees.We obtain data on 415 nursing homes operating in Iowa between 2013-2017.We descriptively examine the turnover trends in nurse employees and all employees over time by profit status.We evaluate whether profit status is associated with high turnover using pooled linear regressions controlling for nursing home and resident characteristics.Descriptive results show that for-profit facilities had higher turnover of nurse employees (61.1% vs. 49.6%)and all employees (56.6% vs. 45.4%).Results from multivariate regressions show that, compared to non-profit facilities, for-profit facilities had 6.93 percentage points higher (p<0.01)turnover of all employees, and 7.76 percentage points higher (p<0.01)turnover of nurse employees after controlling for facility and resident characteristics.Given existing evidence on the adverse impact of high employee turnover on nursing home quality, we need policies aimed at lowering employee turnover, targeting for-profit nursing homes.

ADVANCE DIRECTIVE COMPLETION AND HOSPITAL OUT-OF-POCKET EXPENDITURES
Yujun Zhu, 1 and Susan Enguidanos, 2 1.University of Southern California, South Pasadena, California, United States, 2. University of Southern California, Los Angeles, California, United States Healthcare costs remain high at end of life.Although advance directives (AD) have been shown to improve care congruence with patients' preferences and lower cost of healthcare services, little is known about the relationship between AD completion and hospital out-of-pocket costs.This study examined whether AD completion was associated with lower hospital out-of-pocket spending at end of life.We used the Health and Retirement Study participants who died between 2000 and 2014 (N=9,228) to examine the association through the use of a two-part analytic model that has been widely used in health economics.We controlled for socioeconomic status, death-related characteristics, and health insurance coverage and imputed missing data using multiple imputation by chained equations.Of the 43.9% of decedents who completed an AD, 90.7% chose to limit care or to be kept comfortable; 78.8% indicated that they wanted to withhold treatment, and 5.6% wanted to prolong life.Having an AD was significantly associated with $632 (95% CI: [-$1,116.47,-$146.71])lower hospital out-ofpocket costs, with greater savings among younger decedents, dropping from $1,560 (95% CI: [-$2,652, -$268]) at age 50 to $230 (95% CI: [-$445, -$14]) at age 110.Decedents who completed an AD 12 months or less before death had higher out-of-pocket spending ($1,591 on average) than those who completed more than a year before death ($1,001 on average).Our findings have policy implications for physician-patient communication about costs of care and may provide an opportunity for physicians to involve cost-sharing discussions when completing ADs with patients.

BEREAVEMENT SUPPORT SERVICES IN A NATIONAL SAMPLE OF HOSPICES: A CONTENT ANALYSIS
Todd Becker, and John Cagle, University of Maryland, Baltimore, Baltimore, Maryland, United States Although the Medicare Hospice Benefit mandates that hospices provide bereavement services to families for 1 year following death, it does not stipulate what services should be offered or how.Thus, this study aimed to explore the range of hospice bereavement services.This study stems from Cagle et al.'s (2020) prior study surveying 600 randomly selected agencies, stratified by state and profit status.Most participants (N = 76) worked as clinical supervisors or directors of patient services (41.6%) for medium-sized (53.2%), for-profit hospices (50.6%).Responses to "What types of bereavement support does your hospice provide to families?" were content analyzed.Analyst triangulation and peer debriefing enhanced trustworthiness.Four domains emerged: timing of support, providers of support, targets of support, and formats of support.Each domain reflected substantial variability.All hospices offered postdeath bereavement support.A minority described offering predeath support, often through bereavement risk assessment and supportive services targeting those at risk.Providers frequently included trained bereavement counselors, social workers, and chaplains.Less often, hospices leveraged familiar members of the decedents' care team to encourage family participation.Although bereavement services predominantly targeted surviving adult family members of deceased hospice patients, services tailored to children and hospice-unaffiliated community members also emerged.The format of bereavement services demonstrated the widest variability.Commonly reported formats included written materials, support groups, and phone calls.Most hospices employed multiple formats.Although findings are consistent with prior research, the variability in each domain complicates rigorous investigation of which aspects offer the greatest benefit to bereaved family members.

EXPLORING THE CONCEPT OF THE ETHICAL WILL AS A WAY TO LEAVE A LEGACY OF VALUES:
A SCOPING REVIEW Sarah Neller, 1 Gail Towsley, 2 and Mary McFarland, 1 1.University of Utah, Salt Lake City, Utah, United States, 2. University of Utah College of Nursing, Salt Lake City, Utah, United States Ethical wills communicate a legacy of values through non-legal emotional and supportive instruction to others and are distinct from legal or living wills.Employed for centuries, little is known about how and why ethical wills are used.We conducted the first scoping review on ethical wills to survey the breadth of published information and identify how they are defined and utilized.We followed the Joanna Briggs Institute methodology for scoping reviews employing an a priori protocol and PRISMA-ScR reporting guidelines .We searched 14 databases in November 2019 and January 2021 without filtering publication date or type.Our final extraction form included frequently used terms describing content, purpose, and outcomes.Two reviewers independently screened 1,568 results.Final extraction included 51 documents from 1997-2020, which were primarily published in lay or peer-reviewed journals within law, estate and financial planning, and religion; only 6 research articles were identified.Most frequently, descriptors characterized ethical wills as a non-material legacy of values, beliefs, wisdom, and life lessons learned written to family or future generations.Ethical wills were utilized most to be remembered, address mortality, clarify life's meaning, and communicate what matters most.They provided opportunity to learn about self, were considered a gift to both writer and recipient and fostered intergenerational interaction and transcendence.Our findings highlight interdisciplinary utilization and dearth of research on ethical wills.Gerontological research is needed to explore ways ethical wills can be used to enhance generativity and intentional living as individuals age and prepare for the end of life.

FAMILY CONFLICT AND OLDER CHINESE AMERICANS' SELF-EFFICACY IN END-OF-LIFE CARE PLANNING: THE ROLE OF ACCULTURATION
Kaipeng Wang, 1 Fei Sun, 2 Yanqin Liu, 3 and Carson De Fries, 1 1.University of Denver,Denver,Colorado,United States,2. Michigan State University,East Lansing,Michigan,United States,3. Mayo Clinic Arizona,Scottsdale,Arizona,United States Family involvement in end-of-life (EOL) care is critical to ensure older adults' health and quality of life.Older adults' self-efficacy in discussing EOL care plans with family members can facilitate family involvement in EOL care planning.Research shows that family relationships are associated with self-efficacy in discussing EOL care with family members among older Chinese Americans.However, the roles of family conflict and acculturation remain unknown.This study examines the association between family conflict and Hari Sharma, 1 and Lili Xu, 2 1.The University of Iowa, Iowa City, Iowa, United States, 2. University of Iowa, Iowa City, Iowa, United States