There are important regional variations in site of death, according to the authors of a recent study of Medicare claims from 306 regional healthcare markets.1 For example, more than one-third of Manhattan patients were hospitalized at the end of life vs. less than 14% of patients in Ogden, UT; Greely, CO; or Amarillo, TX. Prior studies suggested a nationwide trend, across all ages, toward increasing death at home and decreasing death in the hospital.2

“We wondered how these patterns looked among older, sicker people who commonly would need medical care for troublesome symptoms or progressive complications toward the end of life,” says Jason H. Maley, MD, the lead author of the most recent study. Maley is a fellow in the pulmonary and critical care fellowship, a collaborative program between Beth Israel Deaconess Medical Center and Massachusetts General Hospital.

Maley and colleagues expected to see regional variation to some extent. Variation in healthcare practices, access to care, and intensity of care has been described in previous studies.3 “We were, however, somewhat surprised by the striking degree to which the use of hospitalization and hospice varied across the U.S., even among large metropolitan areas,” Maley reports.

It is unlikely such variation would be entirely due to regional differences in patient preferences or needs at the end of life, according to Maley. More likely, it reflects differences in the availability of primary care and the availability of inpatient hospital beds relative to hospice beds.

The main ethical concern is patients could be receiving different end-of-life care for reasons other than their personal preferences, values, and needs. This could be happening because of differences in rates of referral to hospice or lack of availability of hospice services. Conversely, high density of hospital beds in larger urban areas could result in regional practice patterns toward hospitalization at the end of life.

Regardless of the underlying reasons, says Maley, “we would like all patients to receive care that aligns with their personal values, rather than their end-of-life experience depending on the practice patterns of healthcare where they live.”


  1. Maley JH, Landon BE, Stevens JP. Regional variation in use of end-of-life care at hospitals, intensive care units, and hospices among older adults with chronic illness in the US, 2010 to 2016. JAMA Netw Open 2020;3:e2010810.
  2. Cross SH, Warraich HJ. Changes in the place of death in the United States. N Engl J Med 2019;381:2369-2370.
  3. Barnato AE, Herndon MB, Anthony DL, et al. Are regional variations in end-of-life care intensity explained by patient preferences? A study of the US Medicare population. Med Care 2007;45:386-393.