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Wu WW, Lu FL, Tang CC, Chao FH, Yu TH. Pediatric palliative care utilization by decedent children: A nationwide population-based study, 2002-2017. J Nurs Scholarsh 2023; 55:1116-1125. [PMID: 37917036 DOI: 10.1111/jnu.12908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 04/19/2023] [Accepted: 05/02/2023] [Indexed: 11/03/2023]
Abstract
PURPOSE This study aimed (1) to describe how trends in pediatric palliative care (PPC) utilization changed from 2002 to 2017, and (2) to examine factors predicting PPC utilization among decedent children in Taiwan. DESIGN This retrospective, correlational study retrieved 2002-2017 data from three national claims databases in Taiwan. METHODS Children aged 1 through 18 years who died between January 2002 and December 2017 were included. Pediatric palliative care utilization was defined as PPC enrollment and PPC duration, with enrollment described by frequency (n) and percentage (%) and duration described by mean and standard deviation (SD). Logistic regression was used to examine the associations of various demographic characteristics with PPC enrollment; generalized linear regression was used to examine associations of the demographic characteristics with PPC duration. FINDINGS Across the 16-year study period, PPC enrollment increased sharply (15.49 times), while PPC duration decreased smoothly (by 29.41%). Cause of death was a continuous predictor of both PPC enrollment and PPC duration. The children less likely to be enrolled in PPC services were those aged 1 to 6 years, boys, living in poverty, living in rural areas, and diagnosed with life-threatening noncancer diseases. CONCLUSION This study used nationwide databases to investigate PPC enrollment and PPC duration among a large sample of deceased children from 2002 to 2017. The findings not only delineate trends and predictors of PPC enrollment and PPC duration but also highlight great progress in PPC as well as the areas still understudied and underserved. This information could help the pediatric healthcare system achieve the core value of family-centered care for children with life-threatening diseases and their families. CLINICAL RELEVANCE Pediatric palliative care should be widely and continuously implemented in routine pediatric clinical practice to enhance quality of life for children and their families at the end of life.
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Affiliation(s)
- Wei-Wen Wu
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Frank L Lu
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Chia-Chun Tang
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Fang-Hsin Chao
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Tsung-Hsien Yu
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
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Hasegawa T, Ito Y, Furukawa Y, Okuyama T, Kojima N, Uchida M, Tasaki Y, Suzuki N, Ishida K, Kashima S, Kubota Y, Akechi T. Specialized Palliative Care and Intensity of End-of-Life Care Among Adolescents and Young Adults with Cancer: A Medical Chart Review. J Adolesc Young Adult Oncol 2023; 12:488-495. [PMID: 36508269 DOI: 10.1089/jayao.2022.0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose: Adolescents and young adults (AYAs) with cancer often undergo aggressive end-of-life (EOL) care. We evaluated whether specialized palliative care (SPC) involvement is associated with the receipt of intensive EOL care among AYAs. Methods: This retrospective study included patients with cancer treated between the ages of 15 and 39 years at a university hospital, who died during 2009-2022. The primary outcome was high-intensity EOL (HI-EOL) care, which was defined as ≥1 session of intravenous chemotherapy <14 days from death or during the final 30 days of life, ≥1 hospitalization at an intensive care unit, >1 emergency room admission, or >1 hospitalization at an acute care unit during the final 30 days of life. We determined predictors of outcomes using multiple logistic regression models. Results: We analyzed 132 AYAs (75 with SPC involvement), of whom 42.4% (95% confidence interval [CI]: 33.9%-51.3%) underwent HI-EOL care. The prevalence of HI-EOL care was significantly lower in those who had SPC involvement than in those without SPC involvement (adjusted odds 0.30; 95% CI: 0.13-0.69; p = 0.005). Using no SPC involvement group as a reference, the adjusted odds for SPC involvement ≤60 days and >60 days were 0.71 (95% CI: 0.18-2.78; p = 0.63) and 0.22 (95% CI: 0.09-0.57; p = 0.002), respectively. Conclusion: In AYAs with cancer, SPC involvement and duration were associated with a lower incidence of HI-EOL care. Thus, integrating SPC into oncology may improve EOL care for AYAs.
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Affiliation(s)
- Takaaki Hasegawa
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
| | - Yoshinori Ito
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
| | - Yosuke Furukawa
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
- Department of Nursing, Nagoya City University Hospital, Nagoya, Japan
| | - Toru Okuyama
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
- Department of Psychiatry, Nagoya City University West Medical Center, Nagoya, Japan
- Center for Psycho-oncology and Palliative Care, Nagoya City University West Medical Center, Nagoya, Japan
| | - Nanako Kojima
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
| | - Megumi Uchida
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yoshihiko Tasaki
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
- Department of Clinical Pharmaceutics, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Nana Suzuki
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
- Center for Psycho-oncology and Palliative Care, Nagoya City University West Medical Center, Nagoya, Japan
| | - Kyoko Ishida
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
- Department of Nursing, Nagoya City University Hospital, Nagoya, Japan
| | - Shuuto Kashima
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
- Department of Rehabilitation Medicine, Nagoya City University Hospital, Nagoya, Japan
| | - Yosuke Kubota
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Tatsuo Akechi
- Center for Psycho-oncology and Palliative Care, Nagoya City University Hospital, Nagoya, Japan
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Widger K, Brennenstuhl S, Nelson KE, Seow H, Rapoport A, Siden H, Vadeboncoeur C, Gupta S, Tanuseputro P. Intensity of end-of-life care among children with life-threatening conditions: a national population-based observational study. BMC Pediatr 2023; 23:375. [PMID: 37488553 PMCID: PMC10364373 DOI: 10.1186/s12887-023-04186-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 07/12/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Children with life-threatening conditions frequently experience high intensity care at the end of life, though most of this research only focused on children with cancer. Some research suggests inequities in care provided based on age, disease type, socioeconomic status, and distance that the child lives from a tertiary hospital. We examined: 1) the prevalence of indicators of high intensity end-of-life care (e.g., hospital stays, intensive care unit [ICU] stays, death in ICU, use of cardiopulmonary resuscitation [CPR], use of mechanical ventilation) and 2) the association between demographic and diagnostic factors and each indicator for children with any life-threatening condition in Canada. METHODS We conducted a population-based retrospective cohort study using linked health administrative data to examine care provided in the last 14, 30, and 90 days of life to children who died between 3 months and 19 years of age from January 1, 2008 to December 31, 2014 from any underlying life-threatening medical condition. Logistic regression was used to model the association between demographic and diagnostic variables and each indicator of high intensity end-of-life care except number of hospital days where negative binomial regression was used. RESULTS Across 2435 child decedents, the most common diagnoses included neurology (51.1%), oncology (38.0%), and congenital illness (35.9%), with 50.9% of children having diagnoses in three or more categories. In the last 30 days of life, 42.5% (n = 1035) of the children had an ICU stay and 36.1% (n = 880) died in ICU. Children with cancer had lower odds of an ICU stay (OR = 0.47; 95% CI = 0.36-0.62) and ICU death (OR = 0.37; 95%CI = 0.28-0.50) than children with any other diagnoses. Children with 3 or more diagnoses (vs. 1 diagnosis) had higher odds of > 1 hospital stay in the last 30 days of life (OR = 2.08; 95%CI = 1.29-3.35). Living > 400 km (vs < 50 km) from a tertiary pediatric hospital was associated with higher odds of multiple hospitalizations (OR = 2.09; 95%CI = 1.33-3.33). CONCLUSION High intensity end of life care is prevalent in children who die from life threatening conditions, particularly those with a non-cancer diagnosis. Further research is needed to understand and identify opportunities to enhance care across disease groups.
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Affiliation(s)
- Kimberley Widger
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.
- Hospital for Sick Children, Toronto, Canada.
| | - Sarah Brennenstuhl
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | | | | | - Adam Rapoport
- Hospital for Sick Children, Toronto, Canada
- Emily's House Children's Hospice, Toronto, Canada
| | - Harold Siden
- Canuck Place Children's Hospice, Vancouver, Canada
- British Columbia Children's Hospital, Vancouver, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Christina Vadeboncoeur
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
- CHEO, Ottawa, Canada
- Roger Neilson House, Ottawa, Canada
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Wolff S, Christiansen CF, Johnsen SP, Schroeder H, Darlington A, Neergaard MA. Disparities in intensity of treatment at end-of-life among children according to the underlying cause of death. Acta Paediatr 2021; 110:1673-1681. [PMID: 33289933 DOI: 10.1111/apa.15713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/15/2020] [Accepted: 12/04/2020] [Indexed: 11/28/2022]
Abstract
AIM To compare indicators of high-intensity treatment at end-of-life (HI-EOL) among children according to causes of death. METHODS We conducted a nationwide registry study in Denmark among 938 children of 1-17 years of age who died from natural causes from 2006 to 2016. We identified and compared indicators of HI-EOL within the last month of life across diagnoses. Indicators were hospital admissions, days in hospital, intensive care unit admission, mechanical ventilation, and hospital death. RESULTS Proportions of each indicator of HI-EOL ranged from 27% to 75%. The most common indicators were hospital death (75%) and ICU admission (39%). Compared to children with solid tumours, children with non-cancerous conditions had an adjusted odds ratio of 3.5 (95% CI 2.1-5.9) of having ≥3 indicators of HI-EOL within the last month of life and children with haematological cancer had an odds ratio of 11.8 (95% CI 6.1-23.0). CONCLUSION The underlying diagnosis was strongly associated with HI-EOL. Children who died from solid tumours experienced substantially less intensive treatment than both children with haematological cancer and non-cancerous conditions did. Across non-cancerous diagnoses, the intensity of treatment appeared consistent, which may indicate, that the awareness of palliative care is higher among oncologists than within other paediatric fields.
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Affiliation(s)
- Sanne Wolff
- Palliative Care Unit Department of Oncology Aarhus University Hospital Aarhus Denmark
- Department of Clinical Epidemiology Aarhus University Aarhus Denmark
| | | | - Soeren Paaske Johnsen
- Department of Clinical Medicine Danish Center for Clinical Health Services Research Aalborg University Aalborg Denmark
| | - Henrik Schroeder
- Department of Paediatrics and Adolescent Medicine Aarhus University Hospital Aarhus Denmark
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Colombet I, Bouleuc C, Piolot A, Vilfaillot A, Jaulmes H, Voisin-Saltiel S, Goldwasser F, Vinant P. Multicentre analysis of intensity of care at the end-of-life in patients with advanced cancer, combining health administrative data with hospital records: variations in practice call for routine quality evaluation. BMC Palliat Care 2019; 18:35. [PMID: 30953487 PMCID: PMC6451228 DOI: 10.1186/s12904-019-0419-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 03/27/2019] [Indexed: 01/03/2023] Open
Abstract
Background Accessible indicators of aggressiveness of care at the end-of-life are useful to monitor implementation of early integrated palliative care practice. To determine the intensity of end-of-life care from exhaustive data combining administrative databases and hospital clinical records, to evaluate its variability across hospital facilities and associations with timely introduction of palliative care (PC). Methods For this study designed as a decedent series nested in multicentre cohort of advanced cancer patients, we selected 997 decedents from a cohort of patients hospitalised in 2009–2010, with a diagnosis of metastatic cancer in 3 academic medical centres and 2 comprehensive cancer centres in the Paris area. Hospital data was combined with nationwide mortality databases. Complete data were collected and checked from clinical records, including first referral to PC, chemotherapy within 14 days of death, ≥1 intensive care unit (ICU) admission, ≥2 emergency department visits (ED), and ≥ 2 hospitalizations, all within 30 days of death. Results Overall (min-max) indicator values as reported by facility providing care rather than the place of death, were: 16% (8–25%) patients received chemotherapy within 14 days of death, 16% (6–32%) had ≥2 admissions to acute care, 6% (0–15%) had ≥2 emergency visits and 18% (4–35%) had ≥1 intensive care unit admission(s). Only 53% of these patients met the PC team, and the median (min-max) time between the first intervention of the PC team and death was 41 (17–112) days. The introduction of PC > 30 days before death was independently associated with lower intensity of care. Conclusions Aggressiveness of end-of-life cancer care is highly variable across centres. This validates the use of indicators to monitor integrated PC in oncology. Disseminating a quality audit-feedback cycle should contribute to a shared view of appropriate end-of-life care objectives, and foster action for improvement among care providers.
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Affiliation(s)
- Isabelle Colombet
- Unité Fonctionnelle de Médecine Palliative, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, F-75014, Paris, France. .,Univ Paris Descartes, F-75006, Paris, France.
| | - Carole Bouleuc
- Département de Soins de Support, Institut Curie, Paris, France
| | - Alain Piolot
- Unité Mobile d'Accompagnement et de Soins Palliatifs, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris, F-94000, Créteil, France
| | - Aurélie Vilfaillot
- Unité de Recherche Clinique, Hôpital européen G Pompidou, Hôpitaux Universitaire Paris Ouest, Assistance Publique Hôpitaux de Paris, F-75015, Paris, France
| | - Hélène Jaulmes
- Unité Mobile d'Accompagnement et de Soins Palliatifs, Hôpital européen G Pompidou, Hôpitaux Universitaire Paris Ouest, Assistance Publique Hôpitaux de Paris, F-75015, Paris, France
| | - Sabine Voisin-Saltiel
- Unité Mobile d'Accompagnement et de Soins Palliatifs, Institut Gustave Roussy, Villejuif, France
| | - François Goldwasser
- Oncologie, Hôpital Cochin, Hôpitaux Universitaire Paris Centre, Assistance Publique Hôpitaux de Paris, F-75014, Paris, France
| | - Pascale Vinant
- Unité Fonctionnelle de Médecine Palliative, Hôpital Cochin, Assistance Publique Hôpitaux de Paris, F-75014, Paris, France
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Revon-Rivière G, Pauly V, Baumstarck K, Bernard C, André N, Gentet JC, Seyler C, Fond G, Orleans V, Michel G, Auquier P, Boyer L. High-intensity end-of-life care among children, adolescents, and young adults with cancer who die in the hospital: A population-based study from the French national hospital database. Cancer 2019; 125:2300-2308. [PMID: 30913309 DOI: 10.1002/cncr.32035] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 12/17/2018] [Accepted: 01/25/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Efforts to improve the quality of end-of-life (EOL) care depend on better knowledge of the care that children, adolescents, and young adults with cancer receive, including high-intensity EOL (HI-EOL) care. The objective was to assess the rates of HI-EOL care in this population and to determine patient- and hospital-related predictors of HI-EOL from the French national hospital database. METHODS This was a population-based, retrospective study of a cohort of patients aged 0 to 25 years at the time of death who died at hospital as a result of cancer in France between 2014 and 2016. The primary outcome was HI-EOL care, defined as the occurrence of ≥1 chemotherapy session <14 days from death, receiving care in an intensive care unit ≥1 time, >1 emergency room admission, and >1 hospitalization in an acute care unit in the last 30 days of life. RESULTS The study included 1899 individuals from 345 hospitals; 61.4% experienced HI-EOL care. HI-EOL was increased with social disadvantage (adjusted odds ratio [AOR], 1.30; 95% confidence interval [CI], 1.03-1.65; P = .028), hematological malignancies (AOR, 2.09; 95% CI, 1.57-2.77; P < .001), complex chronic conditions (AOR, 1.60; 95% CI, 1.23-2.09; P = .001) and care delivered in a specialty center (AOR, 1.70; 95% CI, 1.22-2.36; P = .001). HI-EOL was reduced in cases of palliative care (AOR, 0.31; 95% CI, 0.24-0.41; P < .001). CONCLUSION A majority of children, adolescents, and young adults experience HI-EOL care. Several features (eg, social disadvantage, cancer diagnosis, complex chronic conditions, and specialty center care) were associated with HI-EOL care. These findings should now be discussed with patients, families, and professionals to define the optimal EOL.
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Affiliation(s)
- Gabriel Revon-Rivière
- Department of Pediatric Hematology and Oncology, La Timone Children's Hospital, APHM, Marseille, France
- Fédération des Équipes Ressources Régionales de Soins Palliatifs Pédiatriques
| | - Vanessa Pauly
- Aix-Marseille University, EA 3279 CEReSS - Health Service Research and Quality of Life Center, Marseille, France
- Department of Medical Information, APHM, Marseille, France
| | - Karine Baumstarck
- Aix-Marseille University, EA 3279 CEReSS - Health Service Research and Quality of Life Center, Marseille, France
| | - Cecile Bernard
- Aix-Marseille University, EA 3279 CEReSS - Health Service Research and Quality of Life Center, Marseille, France
| | - Nicolas André
- Department of Pediatric Hematology and Oncology, La Timone Children's Hospital, APHM, Marseille, France
| | - Jean-Claude Gentet
- Department of Pediatric Hematology and Oncology, La Timone Children's Hospital, APHM, Marseille, France
| | | | - Guillaume Fond
- Aix-Marseille University, EA 3279 CEReSS - Health Service Research and Quality of Life Center, Marseille, France
- Department of Medical Information, APHM, Marseille, France
| | | | - Gérard Michel
- Department of Pediatric Hematology and Oncology, La Timone Children's Hospital, APHM, Marseille, France
- Aix-Marseille University, EA 3279 CEReSS - Health Service Research and Quality of Life Center, Marseille, France
| | - Pascal Auquier
- Aix-Marseille University, EA 3279 CEReSS - Health Service Research and Quality of Life Center, Marseille, France
| | - Laurent Boyer
- Aix-Marseille University, EA 3279 CEReSS - Health Service Research and Quality of Life Center, Marseille, France
- Department of Medical Information, APHM, Marseille, France
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Ho JC, Hsieh ML, Chuang PH, Hsieh VCR. Cost-Effectiveness of Sorafenib Monotherapy and Selected Combination Therapy with Sorafenib in Patients with Advanced Hepatocellular Carcinoma. Value Health Reg Issues 2018; 15:120-126. [PMID: 29704658 DOI: 10.1016/j.vhri.2017.12.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 11/29/2017] [Accepted: 12/03/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To evaluate the cost-effectiveness of sorafenib treatment in combination with other therapies versus sorafenib monotherapy among patients with advanced hepatocellular carcinoma (HCC) who are enrolled in Taiwan's National Health Insurance. METHODS A Markov model was constructed to simulate treatment outcomes and direct medical costs of sorafenib combination therapy and monotherapy from the perspective of the healthcare payer in Taiwan. Both life-years (LYs) and quality-adjusted life-years (QALYs) were used to measure treatment outcomes, and all costs were expressed in 2014 New Taiwan dollars (NT$). Model parameters were acquired primarily using data from population-based administrative databases: the Cancer Registry, National Health Insurance Research Database, and the Death Registry. Willingness-to-pay (WTP) threshold was set at three times the per capita gross domestic product at NT$2,133,930. Deterministic and probabilistic sensitivity analyses were conducted. RESULTS For advanced HCC patients, sorafenib combined with other treatments might not be a cost-effective option when compared with sorafenib therapy alone. In the base-case analysis, combination treatment with sorafenib was estimated to increase costs by NT$434,788 compared with monotherapy, with a gain of 0.1595 QALYs. The resulting incremental cost-effectiveness ratio (ICER) was NT$2,725,943 per QALY gained. Results were sensitive to health utility values and monthly costs accrued in the progression-free survival state of the combination therapy group. CONCLUSIONS Our evidence from Taiwan demonstrated that while sorafenib in combination with other therapeutic approaches might improve treatment outcome when compared with sorafenib monotherapy, its ICER exceeded the WTP threshold and was considered not cost-effective.
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Affiliation(s)
- Jung-Chen Ho
- Department of Public Health, China Medical University, Taichung, Taiwan; Central Division, National Health Insurance Administration, Ministry of Health and Welfare, Taiwan
| | - Meng-Lun Hsieh
- Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan; School of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Po-Heng Chuang
- Division of Hepatogastroenterology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Vivian Chia-Rong Hsieh
- Department of Health Services Administration, China Medical University, Taichung, Taiwan.
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8
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Chen B, Fan VY, Chou YJ, Kuo CC. Costs of care at the end of life among elderly patients with chronic kidney disease: patterns and predictors in a nationwide cohort study. BMC Nephrol 2017; 18:36. [PMID: 28122500 PMCID: PMC5267416 DOI: 10.1186/s12882-017-0456-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 01/19/2017] [Indexed: 11/25/2022] Open
Abstract
Background Despite the urgent need for evidence to guide the end-of-life (EOL) care for patients with chronic kidney disease (CKD), we have limited knowledge of the costs and intensity of EOL care in this population. The present study examined patterns and predictors for EOL care intensity among elderly patients with CKD. Methods We conducted a retrospective nationwide cohort study utilizing the Taiwan National Health Insurance (NHI) Research Database. A total of 65,124 CKD patients aged ≥ 60 years, who died in hospitals or shortly after discharge between 2002 and 2012 were analyzed. The primary outcomes were inpatient expenses and use of surgical interventions in the last 30 days of life. Utilization of intensive care unit (ICU), mechanical ventilation, resuscitation, and dialysis was also examined in a sub-sample of 2072 patients with detailed prescription data. Multivariate log-linear and logistic regression analyses were performed to assess patient-, physician-, and facility-specific predictors and the potential impact of a 2009 payment policy to reimburse hospice care for non-cancer patients. Results During the last 30 days of life, average inpatients costs for elderly CKD patients were approximately US$10,260, with 40.9% receiving surgical interventions, 40.2% experiencing ICU admission, 45.3% undergoing mechanical ventilation, 14.7% receiving resuscitation and 42.0% receiving dialysis. Significant variability was observed in the inpatient costs and use of intensive services. Costs were lower among individuals with the following characteristics: advanced age; high income; high Charlson Comorbidity Index scores; treatment by older physicians, nephrologists, and family medicine physicians; and treatment at local hospitals. Similar findings were obtained for the use of surgical interventions and other intensive services. A declining trend was detected in the costs of EOL care, use of surgical interventions and resuscitation between 2009 and 2012, which is consistent with the impact of a 2009 NHI payment policy to reimburse non-cancer hospice care. Conclusions Overall EOL costs and rates of intensive service use among older patients with CKD were high, with significant variability across various patient and provider characteristics. Several opportunities exist for providers and policy makers to reduce costs and enhance the value of EOL care for this population.
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Affiliation(s)
- Bradley Chen
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Victoria Y Fan
- Department of Public Health Sciences & Epidemiology, University of Hawaii at Manoa, 1960 East-West Road, Biomed D204, Honolulu, HI, USA.,François-Xavier Bagnoud Center for Health and Human Rights, Harvard T.H. Chan School of Public Health, 651 Huntington Ave, Boston, MA, USA.,Center for Global Development, Washington, D.C., USA
| | - Yiing-Jenq Chou
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.,Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
| | - Chin-Chi Kuo
- Big Data Center, China Medical University Hospital, Taichung, Taiwan. .,Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, 13F.-2, No.101, Kaixuan Rd., East Dist, Tainan City, Taiwan.
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