APPENDIX: Supplementary Materials for Advance Directives And Nursing. Home Stays Associated With Less Aggressive End-Of-Life Care For

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1 Nicholas LH, Bynum JPW, Iwashnya TJ, Weir DR, Langa KM. Advance directives and nursing home stays associated with less aggressive end-of-life care for patients with severe dementia. Health Aff (MIllwood). 2014;33(4). APPENDIX: Supplementary Materials for Advance Directives And Nursing Home Stays Associated With Less Aggressive End-Of-Life Care For Patients With Severe Dementia Sample Construction We used data from several components of the Health and Retirement Study (HRS). Appendix Exhibit 1 summarizes these data products. Prior to death, HRS respondents are interviewed biennially; a postmortem interview with a next-of-kin proxy informant collects additional information. Proxy informants also respond to biennial surveys when respondents are alive but cognitively unable to participate. Oral informed consent was obtained from participants and proxies in the original study. The institutional review board of the University of Michigan approved the HRS study protocol. We assessed cognition using self or proxy-reported measures of cognition at the last pre-mortem interview. HRS self-respondents receive a 27-point cognitive assessment testing immediate and delayed recall (memory), serial 7 subtractions, and counting backwards. Proxy informants describe cognition when respondents are unable to complete the interview. For respondents represented by proxies, the proxy rates the respondent s memory (excellent to poor) and limitations in five instrumental activities of daily living (IADLs). In addition, the survey interviewer assesses whether the respondent had cognitive

2 limitations that prevented them from completing the interview on their own. Proxy and interviewer information was combined to create an 11- point scale for cognitive function, which was cross-walked to cognition diagnoses based on the subset of HRS respondents participating in the ADAMS study, for whom physician exams and survey responses were available. On average, the last interview for severe dementia patients occurred 341 days before death, compared to 463 days for mild dementia/cind, and 462 days for those with normal cognition. Survey measures of cognition were not available for decedents whose last interview was prior to We used the Chronic Conditions Warehouse (CCW) Medicare claims data indicator for Alzheimer s and related dementias to classify these patients as having dementia if they had met the CCW criteria. Otherwise, we categorized them as having normal cognition, as a conservative strategy for maintaining these respondents in the sample. Our results were robust to excluding this group altogether. So that we can analyze full year of death cohorts and maximize sample size, we prefer specifications including Regression Analysis We used general linear models with a log link and gamma distribution to model Medicare spending (adjusted to 2007 dollars using the medical consumer price index) and a logit link for dichotomous treatment measures to test for differences in healthcare

3 utilization in the last six months of life among patients with normal cognition, CIND / mild dementia, and severe dementia. The general linear model uses a link function, g(y) to transform the expectation of the outcome Y conditional on covariates x as a linear function. For spending, we estimate ln(y x) = Xβ (1) where Y (Medicare spending in the last six months of life) follows a gamma distribution with variance proportional to the mean. This specification addresses two common concerns in healthcare cost modeling; a right-skewed distribution with a small number of patients contributing very high spending, and a mass at $0 spending, which characterizes even our end-of-life sample. Our remaining outcomes are dichotomous indicators of treatment receipt: whether any hospitalizations, ICU stays, life-sustaining treatments, burdensome transfers, in-hospital death, and hospice use. The burdensome transfer variable is equal to one if a patient experiences any of the following: transfers in the last 3 days of life, multiple hospitalizations in the last 90 days of life, or a lack of continuity of nursing home facilities before and after a hospitalization in the last 90 days of life. Lack of continuity is observed only for patients with Medicare-covered skilled nursing admissions pre and post-hospitalization. W use a binomial distribution and a logit link function for dichotomous dependent variables, so the GLM specification is the standard logistic regression model.

4 Control Variables All of our regressions include controls for patient sex, non- White race, Hispanic ethnicity, marital status at previous interview (divorced, widowed, never married or missing relative to the omitted category; married), five-year age group, whether middle or highest wealth tertile (relative to lowest), year of death, supply of nursing home beds per capita among the age 65 population in the decedent s county and state in the year prior to death, and indicators for quartile of Hospital Referral region Medicare spending in the last year of life. Regression Specifications We first compared end-of-life healthcare utilization for patients with normal cognition, cognitive impairment non-dementia, and dementia, allowing the effects to differ for decedents who spent at least some of their end-of-life period in a nursing home: g(y) = αc + γn + δc*n + βx + ε (2) where C is a vector of cognition categories, N indicates nursing home use and X includes the control variables described above. We estimated Equation (2) for the full sample and separately for patients. We then compared end-of-life healthcare utilization for patients with and without advance directives by level of cognition: g(y) = αc + γa + δc*a + βx + ε (3) where A indicates the presence of a written advance directive. Finally, we stratified Equation (3) by nursing home use. We clustered

5 standard errors at the hospital referral region level in all regressions. We used non-linear Wald tests to compare predicted utilization across subgroups of decedents. Sensitivity Analyses We replicated the main findings of differences in treatment by cognitive functioning in a larger sample my including HRS decedents with linked Medicare claims but no proxy post-mortem interview and the subset of deaths occurring from We found similar results comparing spending in the last year of life among decedents with and without the CCW Alzheimer s and related dementia diagnosis using a 5% sample of national Medicare patients in the Beneficiary Annual Summary File. Results were robust to using the CCW dementia measure instead of the survey-based cognition classification, and using the cognition measures without requiring additional ADL limitations.

6 Appendix Exhibit 1: Health and Retirement Study Data Products HRS Tracker File We identify all HRS respondents who die between at age 65 and above HRS Core Survey Interviews Biennial interviews with respondent Proxy informant if respondent is unable to participate We used cognition measures and activities of daily living limitations from last core interview prior to death to characterize decedents as normal cognitive functioning, cognitive impairment non-dememtia/mild dementia, or severe dementia Medicare Administrative Claims Data HRS respondents are asked to consent to have their Medicare claims linked to survey responses, more than 86% consent We restrict sample to respondents continuously enrolled in Fee-for-Service Medicare during the last six months of life because utilization is not observed for those in Medicare Advantage plans. HRS Exit Interviews Post-mortem interviews with next-of-kin informant collect information on respondent health and demographics since last core interview including end-oflife preferences

7 Appendix Exhibit 2: Decedent Utilization and Health Characteristics by Level of Cognitive Impairment and Nursing Home Use in the Last Year of Life Full Sample (N = 3,876) Community-Dwelling (N = 2,064) Any Nursing Home (N = 1,812) Normal CIND/Mild Severe Normal CIND/Mild Severe Normal CIND/Mild Severe Cognition Dementia Dementia Cognition Dementia Dementia Cognition Dementia Dementia (N = (N = (N = (N = (N = (N = (N = (N = (N = 1,367) 1,670) 839) 965) 858) 241) 402) 812) 598) End-of-Life Medicare Utilization Payments within 6 months of death ($1,000s) Hospitalizations (#) Any hospitalization (%) In-hospital death (%) Life-sustaining treatment (%) Intensive Care Unit (%) Decedent Characteristics Treatment-limiting advance directive (%) Female (%)

8 Nonwhite (%) Hispanic (%) Age at death (Years) Had less than high school education (%) High school graduate (%) Divorced (%) Widowed (%) Never married (%) Middle wealth tertile (%) Highest wealth tertile (%) Heart failure (%) ) Valvular disease (%) Hypertension (%) Pulmonary disease (%) Diabetes, uncomplicated (%) Diabetes, complicated (%) Hypothyroidism (%) Fluid and electrolyte disorders (%)

9 Deficiency anemia (%) Source: Authors analysis of Health and Retirement Study Core and Exit interviews linked to Medicare claims for respondents dying between Notes: Mean decedent characteristics for study sample. Community-dwelling sample has no self-report or Medicare skilled nursing home utilization in the last 6 months of life. Cognitive impaired non-dementia (CIND group) includes patients with cognitive functioning consistent with cognitive impairment non-dementia and any number of activities of daily living limitations and patients with cognitive functioning consistent with dementia but fewer than 3 ADL limitations. Dementia group has cognitive functioning consistent with dementia and 3 or more ADL limitations. Unless noted, all cells indicate the proportion of decedents with the characteristic. Household wealth measured in the last interview prior to death and reflects household position (in tertiles) relative to others in the wave.

10 Appendix Exhibit 3: Advance Directives and Medicare Utilization in the Last 6 Months of Life among Normal Cognition, Cognitively Impaired Non-Dementia, and Dementia Patients Treatment-Limiting No Limiting Difference (95% CI) P Value Advance Directive Directive Medicare Spending ($) Normal 31.5 (28.0 to 34.9) 30.1 (27.2 to 32.9) 1.3 (-3.8 to 6.6) CIND 28.4 (26.4 to 30.4) 28.9 (26.5 to 31.2) (-3.3 to 2.4) Dementia 22.2 (19.8 to 24.6) 27.9 (24.1 to 31.7) -5.7 (-9.7 to -1.7) In-hospital death Normal 29.1 (25.6 to 32.7) 32.6 (29.0 to 36.1) -3.4 (-8.2 to 1.4) CIND 23.2 (19.1 to 27.2) 28.7 (26.1 to 31.4) -5.6 (-10.2 to -0.9) Dementia 15.0 (11.3 to 18.7) 24.8 (21.4 to 28.3) -9.8 (-15.2 to -4.5) < Lifesaving Treatment Normal 15.4 (12.2 to 18.7) 17.3 (14.9 to 19.6) -1.8 (-5.9 to 2.3) 0.390

11 CIND 13.7 (10.7 to 16.6) 15.9 (13.7 to 18.0) -2.2 (-5.6 to 1.2) Dementia 10.5 (7.6 to 13.5) 15.3 (11.5 to 19.1) -4.8 (-9.7 to 0.2) ICU Use Normal 24.0 (20.2 to 27.8) 23.2 (20.2 to 26.2) 0.76 (-3.9 to 5.5) CIND 17.6 (14.3 to 20.9) 19.6 (16.7 to 22.4) -1.9 (-6.3. to 2.5) Dementia 8.4 (5.6 to 11.3) 14.7 (11.6 to 17.8) -6.3 (-10.3 to -2.2) Source: Authors analysis of Health and Retirement Study Core and Exit interviews linked to Medicare claims for respondents dying between Notes: Predicted spending and probabilities of utilization in the last six months of life based on average marginal effects from general linear model and logistic regressions adjusting for cognitive functioning, whether the decedent had a written advance directive specifying limits in treatment, and the interaction between cognition and advance directive status, and decedent characteristics.

12 Appendix Exhibit 4: Full Regression Specifications: Exhibit 2 Medicare Payments in Last 6 Month ($000s) Full Community- Any Sample Dwelling Nursing Home In-hospital Death (%) Lifesaving Treatment (%) ICU Use (%) Full Sample Community- Dwelling Any Nursing Home Full Sample Community- Dwelling Any Nursing Home Full Sample Community- Dwelling CIND -4,091*** -3,489** -4,040** ** * *** [1,122] [1,445] [1,712] [0.013] [0.020] [0.024] [0.017] [0.023] [0.026] [0.014] [0.018] [0.021] Dementia -5,736*** *** * * 10,596*** 0.090*** 0.114*** 0.071*** 0.110*** [1,758] [2,512] [1,980] [0.018] [0.025] [0.024] [0.019] [0.026] [0.026] [0.020] [0.028] [0.024] Limiting advance 9,604*** 11,199*** 7,365*** * ** *** directive 0.043*** 0.091*** 0.093*** [1,045] [1,301] [1,431] [0.014] [0.019] [0.020] [0.013] [0.019] [0.020] [0.013] [0.017] [0.020] Medium spending 3,298** 4,076** ** * region [1,366] [1,918] [1,968] [0.023] [0.027] [0.024] [0.018] [0.023] [0.024] [0.014] [0.018] [0.019] High spending 11,624*** 14,502*** 7,270*** * 0.069** *** 0.101*** 0.064*** region [2,504] [3,470] [2,745] [0.024] [0.030] [0.028] [0.026] [0.033] [0.030] [0.019] [0.024] [0.023] Congestive heart 1,498 1, ** ** ** failure [1,738] [2,616] [2,053] [0.022] [0.029] [0.032] [0.025] [0.033] [0.038] [0.019] [0.029] [0.028] Valvular disease -1,541-3,808 1, * [2,621] [3,635] [3,554] [0.033] [0.040] [0.058] [0.034] [0.041] [0.062] [0.026] [0.030] [0.054] Hypertension 4,353*** 6,061*** * 0.060*** * 0.049* ** [1,373] [1,858] [1,659] [0.017] [0.022] [0.029] [0.019] [0.028] [0.027] [0.014] [0.020] [0.022] Chronic pulmonary 1,671 3,661-1, ** disease [1,716] [2,594] [1,775] [0.018] [0.026] [0.031] [0.019] [0.025] [0.036] [0.018] [0.024] [0.026] Diabetes, uncomplicated 5,172*** 7,150** ** Any Nursing Home

13 Diabetes, complicated [1,940] [2,794] [2,000] [0.022] [0.031] [0.032] [0.025] [0.033] [0.043] [0.016] [0.023] [0.031] 8,054* 9,445 6, ** * [4,351] [6,283] [4,506] [0.036] [0.042] [0.056] [0.045] [0.056] [0.081] [0.027] [0.037] [0.052] Hypothyroidism -1, , Fluid and electrolyte disorders [1,956] [3,252] [2,031] [0.027] [0.039] [0.032] [0.032] [0.045] [0.046] [0.023] [0.032] [0.034] 1,758 1, * [2,036] [2,923] [2,003] [0.024] [0.030] [0.039] [0.028] [0.033] [0.037] [0.021] [0.029] [0.026] Deficiency anemia 8,967*** 12,402*** 4,340** * *** [2,061] [2,876] [1,961] [0.021] [0.028] [0.029] [0.024] [0.028] [0.043] [0.018] [0.022] [0.026] Depression -2,828-3, [2,388] [3,130] [3,528] [0.034] [0.041] [0.050] [0.039] [0.049] [0.059] [0.030] [0.038] [0.046] Divorced -2, [3,015] [3,858] [3,458] [0.038] [0.053] [0.070] [0.039] [0.061] [0.065] [0.031] [0.039] [0.044] Widowed ,710 5, * [2,504] [3,220] [3,480] [0.030] [0.038] [0.044] [0.033] [0.045] [0.046] [0.026] [0.037] [0.040] Never married -4,165-8,756** 2, [2,919] [4,225] [3,645] [0.039] [0.051] [0.069] [0.048] [0.062] [0.064] [0.041] [0.053] [0.073] Female 1, , [1,053] [1,363] [1,549] [0.014] [0.017] [0.023] [0.015] [0.018] [0.024] [0.012] [0.016] [0.023] Nonwhite 7,632*** 6,136*** 13,528*** 0.043* 0.043* * *** 0.081*** 0.121** [1,920] [2,008] [4,263] [0.024] [0.026] [0.047] [0.019] [0.020] [0.047] [0.015] [0.018] [0.050] Under 70 4,656* 7,191** * ** [2,659] [3,360] [3,994] [0.025] [0.035] [0.034] [0.026] [0.032] [0.042] [0.030] [0.035] [0.044] Age 75 to 80 1,371 4,186-5, [2,223] [2,844] [3,694] [0.024] [0.031] [0.033] [0.023] [0.030] [0.036] [0.025] [0.033] [0.027] Age 80 to 85-3,318* ,476* [1,836] [2,416] [3,025] [0.020] [0.026] [0.027] [0.026] [0.031] [0.037] [0.025] [0.032] [0.029] Age 85 to 90-6,484*** -5,645** -9,689*** **

14 [2,001] [2,530] [3,112] [0.021] [0.030] [0.029] [0.026] [0.037] [0.037] [0.020] [0.028] [0.031] Age over 90-12,438*** -10,710*** - 16,826*** *** * *** ** *** *** *** *** [1,960] [2,664] [3,048] [0.021] [0.029] [0.028] [0.025] [0.034] [0.033] [0.018] [0.024] [0.026] Medium asset 1, ** group 0.042*** [1,247] [1,653] [1,778] [0.014] [0.018] [0.029] [0.015] [0.019] [0.027] [0.014] [0.019] [0.026] High asset group 2,710* 3,891* ** ** [1,594] [2,204] [2,018] [0.019] [0.030] [0.033] [0.021] [0.026] [0.034] [0.020] [0.025] [0.032] Less than High -1, School [1,834] [2,916] [2,498] [0.019] [0.030] [0.027] [0.025] [0.033] [0.035] [0.018] [0.029] [0.023] High School -3,326-2,337-4, ** Diploma [2,072] [3,257] [2,585] [0.017] [0.026] [0.027] [0.024] [0.032] [0.026] [0.017] [0.026] [0.019] Separated/Divorced ,588-4, * [3,431] [4,345] [4,142] [0.042] [0.062] [0.061] [0.046] [0.070] [0.061] [0.029] [0.041] [0.041] Widowed/Single ,248-5, * [2,208] [3,010] [3,513] [0.031] [0.042] [0.041] [0.033] [0.041] [0.050] [0.026] [0.034] [0.040] Hispanic 9,717*** 10,087*** [2,922] [3,406] [4,745] [0.026] [0.028] [0.145] [0.029] [0.028] [0.085] [0.022] [0.029] [0.057] Year of Death 671** ** *** *** *** *** *** *** *** *** *** [270] [346] [376] [0.003] [0.004] [0.004] [0.003] [0.005] [0.005] [0.003] [0.004] [0.004] SNF beds in state year before death SNF beds in county year before death [73] [101] [95] [0.001] [0.001] [0.001] [0.001] [0.001] [0.001] [0.001] [0.001] [0.001] [43] [51] [59] [0.001] [0.001] [0.001] [0.001] [0.001] [0.001] [0.000] [0.001] [0.001] Observations Source and notes follow Exhibit 2.

15 Appendix Exhibit 5: Full Regression Specifications for Exhibit 3 Medicare Payments in Last 6 Month ($000s) In-hospital Death (%) Lifesaving Treatment (%) Full Sample Community Dwelling Any Nursing Home Full Sample Community Dwelling Any Nursing Home Full Sample Community Dwelling Any Nursing Home CIND -1,880* -3,125*** -5,062** *** * [1,054] [1,204] [2,016] [0.018] [0.025] [0.024] [0.014] [0.020] [0.018] Dementia -4,849*** ,302*** *** *** ** * * [1,506] [2,810] [2,057] [0.018] [0.031] [0.025] [0.017] [0.031] [0.019] Limiting advance ,447** *** ** *** ** ** directive [1,446] [1,885] [1,437] [0.016] [0.021] [0.021] [0.013] [0.018] [0.017] Medium spending 3,012** 4,438** 2,800* ** 0.044** region [1,466] [1,773] [1,522] [0.018] [0.025] [0.021] [0.014] [0.019] [0.020] High spending 11,352*** 13,645*** 9,592*** 0.054** * 0.088*** 0.095*** 0.075*** region [2,504] [2,879] [3,025] [0.026] [0.033] [0.027] [0.019] [0.022] [0.023] Congestive heart 2,262-1,816 4,563** failure [1,723] [2,753] [2,173] [0.025] [0.042] [0.031] [0.019] [0.030] [0.023] Valvular disease -1,976 1,252-4, * [2,731] [3,581] [3,232] [0.034] [0.058] [0.037] [0.026] [0.032] [0.037] Hypertension 5,031*** 5,348*** 3,529* ** ** 0.041** [1,388] [1,766] [2,104] [0.020] [0.027] [0.026] [0.014] [0.019] [0.023] Chronic 1,771 3,503-1, pulmonary disease [1,741] [2,179] [2,509] [0.019] [0.029] [0.027] [0.018] [0.025] [0.023] Diabetes, uncomplicated 5,226*** 5,914** 3,

16 Diabetes, complicated [1,916] [2,533] [2,782] [0.025] [0.037] [0.030] [0.016] [0.022] [0.019] 8,195* 9,473 7, [4,428] [6,666] [6,360] [0.044] [0.082] [0.055] [0.027] [0.046] [0.033] Hypothyroidism -1,141 1,367-3, * [1,948] [2,808] [2,810] [0.032] [0.050] [0.042] [0.023] [0.036] [0.029] Fluid and 2,231 1,906 1, electrolyte disorders [2,040] [2,937] [2,476] [0.027] [0.040] [0.036] [0.021] [0.032] [0.023] Deficiency anemia 9,305*** 12,898*** 5,733** * [2,069] [3,445] [2,708] [0.024] [0.036] [0.032] [0.018] [0.028] [0.022] Depression -1,716-4,368-1, [2,452] [4,095] [3,276] [0.039] [0.069] [0.044] [0.030] [0.055] [0.032] Divorced -1,537-7,669** 4, * [2,930] [3,132] [5,236] [0.039] [0.063] [0.053] [0.031] [0.050] [0.050] Widowed 26-2,311 2, [2,501] [3,145] [3,360] [0.033] [0.050] [0.051] [0.026] [0.040] [0.042] Never married -2,484-3,775-3, [2,993] [4,423] [3,940] [0.048] [0.075] [0.058] [0.041] [0.066] [0.052] Female 1,358 2,909* -1, [1,102] [1,490] [1,442] [0.015] [0.024] [0.022] [0.012] [0.019] [0.016] Nonwhite 6,356*** 6,460*** 7,728*** *** 0.071*** 0.100*** [1,928] [2,397] [2,441] [0.018] [0.025] [0.027] [0.015] [0.023] [0.027] Under 70 3,735 3,328 14,168* * [2,772] [2,797] [7,283] [0.026] [0.035] [0.046] [0.030] [0.036] [0.062] Age 75 to 80 1,441 2,983-2, [2,283] [2,796] [4,217] [0.023] [0.030] [0.039] [0.025] [0.031] [0.034] Age 80 to 85-2,416-4,725** -2, [1,848] [2,229] [3,791] [0.026] [0.034] [0.038] [0.025] [0.032] [0.031] Age 85 to 90-4,521** -5,171* -8,184**

17 [2,006] [2,691] [3,685] [0.026] [0.036] [0.034] [0.020] [0.029] [0.024] Age over 90-9,748*** -10,570*** -13,707*** *** * *** *** 0.084*** [1,980] [2,729] [3,811] [0.024] [0.041] [0.031] [0.019] [0.028] [0.023] Medium asset 1, ,993** * ** * group [1,292] [1,772] [1,858] [0.015] [0.024] [0.021] [0.014] [0.019] [0.020] High asset group 2,218 2,372 3,966* [1,622] [2,195] [2,149] [0.022] [0.032] [0.030] [0.020] [0.027] [0.027] Less than High -1,951-2, School [1,905] [2,949] [2,364] [0.025] [0.034] [0.035] [0.018] [0.029] [0.024] High School -3,450-4,218-1, Diploma [2,131] [3,104] [2,174] [0.024] [0.030] [0.033] [0.017] [0.024] [0.023] Separated/Divorc -1,274 1,537-4, ed [3,365] [3,467] [5,564] [0.046] [0.071] [0.057] [0.030] [0.055] [0.047] Widowed/Single ,570-2, [2,294] [2,882] [2,959] [0.033] [0.050] [0.048] [0.026] [0.040] [0.039] Hispanic 7,476*** 4,363 19,935*** [2,895] [3,635] [4,053] [0.029] [0.039] [0.042] [0.023] [0.032] [0.031] Year of Death 698** 153 1,075*** *** *** *** *** *** 0.033*** [279] [396] [367] [0.003] [0.005] [0.005] [0.003] [0.004] [0.004] SNF beds in state year before death [77] [92] [76] [0.001] [0.001] [0.001] [0.001] [0.001] [0.001] SNF beds in county year before death [41] [60] [46] [0.001] [0.001] [0.001] [0.000] [0.001] [0.001] Observations

18 ICU Use (%) Full Community Nursing Home CIND *** * 0.046*** [0.013] [0.019] [0.018] Dementia *** *** *** [0.015] [0.027] [0.017] Limiting advance directive [0.014] [0.019] [0.016] Medium spending region [0.023] [0.028] [0.030] High spending region [0.023] [0.030] [0.028] Congestive heart failure 0.043* 0.082** [0.023] [0.039] [0.026] Valvular disease [0.033] [0.052] [0.042] Hypertension 0.029* 0.045* [0.017] [0.024] [0.024] Chronic pulmonary disease [0.019] [0.025] [0.024] Diabetes, uncomplicated ** [0.022] [0.029] [0.030] Diabetes, complicated [0.035] [0.066] [0.040]

19 Hypothyroidism Fluid and electrolyte disorders [0.028] [0.039] [0.037] [0.024] [0.034] [0.031] Deficiency anemia * [0.021] [0.036] [0.027] Depression [0.033] [0.063] [0.037] Divorced * [0.037] [0.054] [0.044] Widowed [0.029] [0.042] [0.035] Never married [0.039] [0.060] [0.048] Female * [0.014] [0.021] [0.019] Nonwhite 0.042* [0.023] [0.030] [0.028] Under [0.025] [0.034] [0.036] Age 75 to [0.024] [0.035] [0.030] Age 80 to [0.020] [0.030] [0.027] Age 85 to ** [0.021] [0.031] [0.028] Age over *** ** *** [0.020] [0.033] [0.023]

20 Medium asset group * [0.014] [0.019] [0.021] High asset group [0.020] [0.026] [0.030] Less than High School [0.019] [0.029] [0.030] High School Diploma [0.017] [0.023] [0.027] Separated/Divorced [0.041] [0.071] [0.052] Widowed/Single [0.031] [0.046] [0.037] Hispanic [0.026] [0.028] [0.043] Year of Death *** *** *** [0.003] [0.005] [0.004] SNF beds in state year before death [0.001] [0.001] [0.001] SNF beds in county year before death [0.001] [0.001] [0.001] Observations Source and notes follow Exhibit 3.