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Hi Mark.

This is not an area I have been keeping up with (and I should have done). However, my understanding has always been that, because progressive and fatal illness often requires high intensity care, this has important cost implications (Seshamani and Gray, 2004). And, as we know, older people are far more likely to die than younger people

So, although age has a more modest impact on expenditure than proximity to death in the Wong et al study, this is when the latter is controlled for. As the two things tend to go together, I don't really see age as a red herring when it comes to identifying where the really high demand (and I'd say need) AREAS are lkely to be.

I guess focusing on proximity to death alone could offend those who want resources to reflect capacity to benefit??? However, I can't see many people being happy with the idea of denying older patients with e.g. cancer care that may increase their life expectancy, if only by a few years. That said, we know that cancer treatments do vary by age for clinically justifiable reasons (e.g. in terms of the emphasis placed on chemo and radiotherapy).

I absolutely agree that indicators like utilisation and LoS are blunt tools, primarily because they have been distorted by systematic biases in supply over the past decade or so.

I hope this makes sense (and I haven't got the wrong end of the stick!).

Sheena