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Salaj D, Schultz T, Strang P. Medical costs of Swedish nursing home residents at the end of life: a retrospective observational registry study. BMC Geriatr 2024; 24:580. [PMID: 38965491 PMCID: PMC11225223 DOI: 10.1186/s12877-024-05043-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 05/03/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND There are many studies of medical costs in late life in general, but nursing home residents' needs and the costs of external medical services and interventions outside of nursing home services are less well described. METHODS We examined the direct medical costs of nursing home residents in their last year of life, as well as limited to the period of stay in the nursing home, adjusted for age, sex, Hospital Frailty Risk Score (HFRS), and diagnosis of dementia or advanced cancer. This was an observational retrospective study of registry data from all diseased nursing home residents during the years 2015-2021 using healthcare consumption data from the Stockholm Regional Council, Sweden. T tests, Wilcoxon rank sum tests and chi-square tests were used for comparisons of groups, and generalized linear models (GLMs) were constructed for univariable and multivariable linear regressions of health cost expenditures to calculate risk ratios (RRs) with 95% confidence intervals (95% CIs). RESULTS According to the adjusted (multivariable) models for the 38,805 studied nursing home decedents, when studying the actual period of stay in nursing homes, we found significantly greater medical costs associated with male sex (RR 1.29 (1.25-1.33), p < 0.0001) and younger age (65-79 years vs. ≥90 years: RR 1.92 (1.85-2.01), p < 0.0001). Costs were also greater for those at risk of frailty according to the Hospital Frailty Risk Score (HFRS) (intermediate risk: RR 3.63 (3.52-3.75), p < 0.0001; high risk: RR 7.84 (7.53-8.16), p < 0.0001); or with advanced cancer (RR 2.41 (2.26-2.57), p < 0.0001), while dementia was associated with lower medical costs (RR 0.54 (0.52-0.55), p < 0.0001). The figures were similar when calculating the costs for the entire last year of life (regardless of whether they were nursing home residents throughout the year). CONCLUSIONS Despite any obvious explanatory factors, male and younger residents had higher medical costs at the end of life than women. Having a risk of frailty or a diagnosis of advanced cancer was strongly associated with higher costs, whereas a dementia diagnosis was associated with lower external, medical costs. These findings could lead us to consider reimbursement models that could be differentiated based on the observed differences.
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Affiliation(s)
- Dag Salaj
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Region Örebro län, Box 1613, Örebro, S-701 16, Sweden.
| | | | - Peter Strang
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Region Örebro län, Box 1613, Örebro, S-701 16, Sweden
- R&D Department, Sjukhem Foundation, Stockholm, Sweden
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2
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Johnson EE, Searle B, Lazo Green K, Walbaum M, Barker R, Brotherhood K, Spiers GF, Craig D, Hanratty B. Interventions to Prevent Hospital Admissions in Long-Term Care Facilities: A Rapid Review of Economic Evidence. J Am Med Dir Assoc 2024; 25:105034. [PMID: 38796166 DOI: 10.1016/j.jamda.2024.105034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 05/28/2024]
Abstract
OBJECTIVES Hospital admissions can be hazardous for older adults, particularly those living in long-term care facilities. Preventing nonessential admissions can be beneficial for this population, as well as reducing demand on health services. This review summarizes the economic evidence surrounding effective interventions to reduce hospital attendances and admissions for people living in long-term care facilities. DESIGN Rapid review of economic evidence. SETTING AND PARTICIPANTS People living in long-term facilities. METHODS We searched MEDLINE, CINAHL, Cochrane CENTRAL, PubMed, and Web of Science on September 20, 2022, and again on January 10, 2023. Full economic evaluations and cost analyses reporting on advanced care planning, goals of care setting, nurse practitioner input, palliative care, influenza vaccinations, and enhancing access to intravenous therapies were eligible. Data were extracted using a prepiloted data extraction form and critically appraised using either the Drummond-Jefferson checklist or an amended NIH Critical Appraisal Tool appended with questions from a critical appraisal checklist for cost analyses. Data were synthesized narratively. RESULTS We included 7 studies: 3 full economic evaluations and 4 cost analyses. Because of lack of clarity on the underlying study design, we did not include one of the cost analyses in our synthesis. Advanced care planning, a palliative care program, and a high-dose influenza vaccination reported potential cost savings. Economic evidence for a multicomponent intervention and a nurse practitioner model was inconclusive. The overall quality of the evidence varied between studies. CONCLUSIONS AND IMPLICATIONS A number of potentially cost-effective approaches to reduce demand on hospital services from long-term care facilities were identified. However, further economic evaluations are needed to overcome limitations of the current evidence base and offer more confident conclusions.
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Affiliation(s)
- Eugenie E Johnson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom; NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ben Searle
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.
| | - Kimberly Lazo Green
- School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Magdalena Walbaum
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, United Kingdom
| | - Robert Barker
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Kelly Brotherhood
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Gemma Frances Spiers
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Dawn Craig
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom; NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Barbara Hanratty
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
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3
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Gombault-Datzenko E, Costa N, Mounié M, Tavassoli N, Mathieu C, Roussel H, Lagarrigue JM, Berard E, Rolland Y, Molinier L. Cost of care pathways before and after appropriate and inappropriate transfers to the emergency department among nursing home residents: results from the FINE study. BMC Geriatr 2024; 24:353. [PMID: 38641801 PMCID: PMC11027376 DOI: 10.1186/s12877-024-04946-x] [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: 07/04/2023] [Accepted: 04/03/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Transfers of nursing home (NH) residents to the emergency department (ED) is frequent. Our main objective was to assess the cost of care pathways 6 months before and after the transfer to the emergency department among NH residents, according to the type of transfer (i.e. appropriate or inappropriate). METHODS This was a part of an observational, multicenter, case-control study: the Factors associated with INappropriate transfer to the Emergency department among nursing home residents (FINE) study. Sixteen public hospitals of the former Midi-Pyrénées region participated in recruitment, in 2016. During the inclusion period, all NH residents arriving at the ED were included. A pluri-disciplinary team categorized each transfer to the ED into 2 groups: appropriate or inappropriate. Direct medical and nonmedical costs were assessed from the French Health Insurance (FHI) perspective. Healthcare resources were retrospectively gathered from the FHI database and valued using the tariffs reimbursed by the FHI. Costs were recorded over a 6-month period before and after transfer to the ED. Other variables were used for analysis: sex, age, Charlson score, season, death and presence inside the NH of a coordinating physician or a geriatric nursing assistant. RESULTS Among the 1037 patients initially included in the FINE study, 616 who were listed in the FHI database were included in this economic study. Among them, 132 (21.4%) had an inappropriate transfer to the ED. In the 6 months before ED transfer, total direct costs on average amounted to 8,145€ vs. 6,493€ in the inappropriate and appropriate transfer groups, respectively. In the 6 months after ED transfer, they amounted on average to 9,050€ vs. 12,094€. CONCLUSIONS Total costs on average are higher after transfer to the ED, but there is no significant increase in healthcare expenditure with inappropriate ED transfer. Support for NH staff and better pathways of care could be necessary to reduce healthcare expenditures in NH residents. TRIAL REGISTRATION clinicaltrials.gov, NCT02677272.
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Affiliation(s)
- E Gombault-Datzenko
- Present address: Department of Medical Information (DIM), Toulouse University Hospital, 2 rue Viguerie, Toulouse Cedex 9, 31059, France.
| | - N Costa
- Present address: Department of Medical Information (DIM), Toulouse University Hospital, 2 rue Viguerie, Toulouse Cedex 9, 31059, France
- INSERM, UMR 1295, Toulouse, France
| | - M Mounié
- Present address: Department of Medical Information (DIM), Toulouse University Hospital, 2 rue Viguerie, Toulouse Cedex 9, 31059, France
- INSERM, UMR 1295, Toulouse, France
| | - N Tavassoli
- Gérontopôle, Toulouse University Hospital, Toulouse, France
| | - C Mathieu
- Gérontopôle, Toulouse University Hospital, Toulouse, France
- CREAI-ORS Occitanie, Toulouse, France
| | - H Roussel
- CNAM, DRSM Occitanie, 2 rue Georges Vivent, Toulouse, 31082, France
| | - J M Lagarrigue
- MSA Midi-Pyrénées Nord, 180 Avenue Marcel Unal, Montauban, 82000, France
| | - E Berard
- INSERM, UMR 1295, Toulouse, France
- Department of Epidemiology, University Hospital of Toulouse, 37 Allées Jules Guesde, Toulouse, 31000, France
| | - Y Rolland
- INSERM, UMR 1295, Toulouse, France
- Gérontopôle, Toulouse University Hospital, Toulouse, France
| | - L Molinier
- Present address: Department of Medical Information (DIM), Toulouse University Hospital, 2 rue Viguerie, Toulouse Cedex 9, 31059, France
- INSERM, UMR 1295, Toulouse, France
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4
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Korfage IJ, Polinder S, Preston N, van Delden JJ, Geraerds SAJ, Dunleavy L, Faes K, Miccinesi G, Carreras G, Moeller Arnfeldt C, Kars MC, Lippi G, Lunder U, Mateus C, Pollock K, Deliens L, Groenvold M, van der Heide A, Rietjens JA. Healthcare use and healthcare costs for patients with advanced cancer; the international ACTION cluster-randomised trial on advance care planning. Palliat Med 2022; 37:707-718. [PMID: 36515362 DOI: 10.1177/02692163221142950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Advance care planning supports patients to reflect on and discuss preferences for future treatment and care. Studies of the impact of advance care planning on healthcare use and healthcare costs are scarce. AIM To determine the impact on healthcare use and costs of an advance care planning intervention across six European countries. DESIGN Cluster-randomised trial, registered as ISRCTN63110516, of advance care planning conversations supported by certified facilitators. SETTING/PARTICIPANTS Patients with advanced lung or colorectal cancer from 23 hospitals in Belgium, Denmark, Italy, the Netherlands, Slovenia and the UK. Data on healthcare use were collected from hospital medical files during 12 months after inclusion. RESULTS Patients with a good performance status were underrepresented in the intervention group (p< 0.001). Intervention and control patients spent on average 9 versus 8 days in hospital (p = 0.07) and the average number of X-rays was 1.9 in both groups. Fewer intervention than control patients received systemic cancer treatment; 79% versus 89%, respectively (p< 0.001). Total average costs of hospital care during 12 months follow-up were €32,700 for intervention versus €40,700 for control patients (p = 0.04 with bootstrap analyses). Multivariable multilevel models showed that lower average costs of care in the intervention group related to differences between study groups in country, religion and WHO-status. No effect of the intervention on differences in costs between study groups was observed (p = 0.3). CONCLUSIONS Lower care costs as observed in the intervention group were mainly related to patients' characteristics. A definite impact of the intervention itself could not be established.
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Affiliation(s)
- Ida J Korfage
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nancy Preston
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK
| | - Johannes Jm van Delden
- Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Sandra A Jlm Geraerds
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Lesley Dunleavy
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK
| | - Kristof Faes
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Guido Miccinesi
- Clinical Epidemiology, Oncological network, prevention and research Institute (ISPRO), Florence, Italy
| | - Giulia Carreras
- Clinical Epidemiology, Oncological network, prevention and research Institute (ISPRO), Florence, Italy
| | - Caroline Moeller Arnfeldt
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of Palliative Medicine, The Research Unit, Bispebjerg Hospital, Copenhagen, Denmark
| | - Marijke C Kars
- Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | | | - Urska Lunder
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Ceu Mateus
- Division of Health Research, Lancaster University, Lancaster, UK
| | - Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Mogens Groenvold
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark.,Department of Palliative Medicine, The Research Unit, Bispebjerg Hospital, Copenhagen, Denmark
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Judith Ac Rietjens
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Ersek M, Unroe KT, Carpenter JG, Cagle JG, Stephens CE, Stevenson DG. High-Quality Nursing Home and Palliative Care-One and the Same. J Am Med Dir Assoc 2022; 23:247-252. [PMID: 34953767 PMCID: PMC8821139 DOI: 10.1016/j.jamda.2021.11.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/29/2021] [Accepted: 11/21/2021] [Indexed: 02/03/2023]
Abstract
Many individuals receiving post-acute and long-term care services in nursing homes have unmet palliative and end-of-life care needs. Hospice has been the predominant approach to meeting these needs, although hospice services generally are available only to long-term care residents with a limited prognosis who choose to forego disease-modifying or curative therapies. Two additional approaches to meeting these needs are the provision of palliative care consultation through community- or hospital-based programs and facility-based palliative care services. However, access to this specialized care is limited, services are not clearly defined, and the empirical evidence of these approaches' effectiveness is inadequate. In this article, we review the existing evidence and challenges with each of these 3 approaches. We then describe a model for effective delivery of palliative and end-of-life care in nursing homes, one in which palliative and end-of-life care are seen as integral to high-quality nursing home care. To achieve this vision, we make 4 recommendations: (1) promote internal palliative and end-of-life care capacity through comprehensive training and support; (2) ensure that state and federal payment policies and regulations do not create barriers to delivering high-quality, person-centered palliative and end-of-life care; (3) align nursing home quality measures to include palliative and end-of-life care-sensitive indicators; and (4) support access to and integration of external palliative care services. These recommendations will require changes in the organization, delivery, and reimbursement of care. All nursing homes should provide high-quality palliative and end-of-life care, and this article describes some key strategies to make this goal a reality.
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Affiliation(s)
- Mary Ersek
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA; Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, USA; University of Pennsylvania School of Nursing, Philadelphia, PA, USA.
| | - Kathleen T Unroe
- Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University Center for Aging Research, Indianapolis, IN, USA; Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Joan G Carpenter
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA; University of Pennsylvania School of Nursing, Philadelphia, PA, USA; University of Maryland School of Nursing, Baltimore, MD, USA
| | - John G Cagle
- University of Maryland School of Social Work, Baltimore, MD, USA
| | | | - David G Stevenson
- Veterans Affairs Tennessee Valley Healthcare System, Murfreesboro, TN, USA; Vanderbilt School of Medicine, Nashville, TN, USA
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6
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Buck D, Tucker S, Roe B, Hughes J, Challis D. Hospital admissions and place of death of residents of care homes receiving specialist healthcare services: A systematic review without meta-analysis. J Adv Nurs 2021; 78:666-697. [PMID: 34532884 DOI: 10.1111/jan.15043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 08/09/2021] [Accepted: 08/27/2021] [Indexed: 11/29/2022]
Abstract
AIM To synthesize evidence on the ability of specialist care home support services to prevent hospital admission of older care home residents, including at end of life. DESIGN Systematic review, without meta-analysis, with vote counting based on direction of effect. DATA SOURCES Fourteen electronic databases were searched from January 2010 to January 2019. Reference lists of identified reviews, study protocols and included documents were scrutinized for further studies. REVIEW METHODS Papers on the provision of specialist care home support that addressed older, long-term care home residents' physical health needs and provided comparative data on hospital admissions were included. Two reviewers undertook study selection and quality appraisal independently. Vote counting by direction of effect and binomial tests determined service effectiveness. RESULTS Electronic searches identified 79 relevant references. Combined with 19 citations from an earlier review, this gave 98 individual references relating to 92 studies. Most were from the UK (22), USA (22) and Australia (19). Twenty studies were randomized controlled trials and six clinical controlled trials. The review suggested interventions addressing residents' general health needs (p < .001), assessment and management services (p < .0001) and non-training initiatives involving medical staff (p < .0001) can reduce hospital admissions, while there was also promising evidence for services targeting residents at imminent risk of hospital entry or post-hospital discharge and training-only initiatives. End-of-life care services may enable residents to remain in the home at end of life (p < .001), but the high number of weak-rated studies undermined confidence in this result. CONCLUSION This review suggests specialist care home support services can reduce hospital admissions. More robust studies of services for residents at end of life are urgently needed. IMPACT The review addressed the policy imperative to reduce the avoidable hospital admission of older care home residents and provides important evidence to inform service design. The findings are of relevance to commissioners, providers and residents.
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Affiliation(s)
- Deborah Buck
- Social Care and Society, University of Manchester, Manchester, UK
| | - Sue Tucker
- Social Care and Society, University of Manchester, Manchester, UK
| | - Brenda Roe
- Faculty of Health, Social Care and Medicine, Edge Hill University, Ormskirk, UK
| | - Jane Hughes
- Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - David Challis
- Institute of Mental Health, University of Nottingham, Nottingham, UK
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7
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Evidence on the economic value of end-of-life and palliative care interventions: a narrative review of reviews. BMC Palliat Care 2021; 20:89. [PMID: 34162377 PMCID: PMC8223342 DOI: 10.1186/s12904-021-00782-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/26/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND As the demand for palliative care increases, more information is needed on how efficient different types of palliative care models are for providing care to dying patients and their caregivers. Evidence on the economic value of treatments and interventions is key to informing resource allocation and ultimately improving the quality and efficiency of healthcare delivery. We assessed the available evidence on the economic value of palliative and end-of-life care interventions across various settings. METHODS Reviews published between 2000 and 2019 were included. We included reviews that focused on cost-effectiveness, intervention costs and/or healthcare resource use. Two reviewers extracted data independently and in duplicate from the included studies. Data on the key characteristics of the studies were extracted, including the aim of the study, design, population, type of intervention and comparator, (cost-) effectiveness resource use, main findings and conclusions. RESULTS A total of 43 reviews were included in the analysis. Overall, most evidence on cost-effectiveness relates to home-based interventions and suggests that they offer substantial savings to the health system, including a decrease in total healthcare costs, resource use and improvement in patient and caregivers' outcomes. The evidence of interventions delivered across other settings was generally inconsistent. CONCLUSIONS Some palliative care models may contribute to dual improvement in quality of care via lower rates of aggressive medicalization in the last phase of life accompanied by a reduction in costs. Hospital-based palliative care interventions may improve patient outcomes, healthcare utilization and costs. There is a need for greater consistency in reporting outcome measures, the informal costs of caring, and costs associated with hospice.
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8
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Parackal A, Ramamoorthi K, Tarride JE. Economic Evaluation of Palliative Care Interventions: A Review of the Evolution of Methods From 2011 to 2019. Am J Hosp Palliat Care 2021; 39:108-122. [PMID: 34024147 DOI: 10.1177/10499091211011138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND End-of-life care is a driver of increasing healthcare costs; however, palliative care interventions may significantly reduce these costs. Economic evaluations that measure the incremental cost per quality adjusted life years (QALY) are warranted to inform cost-effectiveness of the intervention relative to a comparator and permit evaluation of investment against other therapeutic interventions. Evidence from the literature up to 2011 indicates a scarcity of cost-utility studies in palliative care research. AIM This literature review evaluates economic studies published between 2011 and 2019 to determine whether the methods of economic evaluations have evolved since 2011. DESIGN AND DATA SOURCES A literature search was completed using CENTRAL, OVID MEDLINE, EMBASE and other sources for publications between 2011 and 2019. Study characteristics, methodology and key findings of publications that met the inclusion criteria were reviewed. Quality of studies were assessed using indicators developed by authors of the previous literature review. RESULTS 46 papers were included for qualitative synthesis. Among them only 6 studies conducted formal cost-effectiveness evaluations-of these 5 measured QALYs and 1 employed probabilistic analyses. In addition, with the exception of 1 costing analysis, all other economic evaluations undertook a healthcare payer perspective. Quality of evidence were comparable to the previous literature review published in 2011. CONCLUSION Despite the small increase in the number of cost-utility studies, the methods of palliative care economic evaluations have not evolved significantly since 2011. More probabilistic cost-utility analyses of palliative care interventions from a societal perspective are necessary to truly evaluate the value for money.
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Affiliation(s)
- Anna Parackal
- Department of Health Research Methods, Evidence & Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Karishini Ramamoorthi
- Department of Health Research Methods, Evidence & Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence & Impact (HEI), McMaster University, Hamilton, Ontario, Canada.,McMaster Chair, Health Technology Management, McMaster University, Hamilton, Ontario, Canada.,Center for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Ontario, Canada.,Programs for Assessment to Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
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9
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Harrison JM, Agarwal M, Stone PW, Gracner T, Sorbero M, Dick AW. Does Integration of Palliative Care and Infection Management Reduce Hospital Transfers among Nursing Home Residents? J Palliat Med 2021; 24:1334-1341. [PMID: 33605787 DOI: 10.1089/jpm.2020.0577] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: An estimated 50% of nursing home (NH) residents experience hospital transfers in their last year of life, often due to infections. Hospital transfers due to infection are often of little clinical benefit to residents with advanced illness, for whom aggressive treatments are often ineffective and inconsistent with goals of care. Integration of palliative care and infection management (i.e., merging the goals of palliative care and infection management at end of life) may reduce hospital transfers for residents with advanced illness. Objectives: Evaluate the association between integration and (1) all-cause hospital transfers and (2) hospital transfers due to infection. Design: Cross-sectional observational study. Setting/Subjects: 143,223 U.S. NH residents, including 42,761 residents in the advanced stages of dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Measurement: Cross-sectional, nationally representative NH survey data (2017-2018) were combined with resident data from the Minimum Data Set 3.0 and Medicare inpatient data (2016-2017). NH surveys measured integration of palliative care and infection management using an index of 0-100. Logistic regression models were used to estimate the relationships between integration intensity (i.e., the degree to which NHs follow best practices for integration) and all-cause hospital transfer and transfer due to infection. Results: Among residents with advanced dementia, integration intensity was inversely associated with all-cause hospital transfer and transfer due to infection (p < 0.001). Among residents with advanced COPD, integration intensity was inversely associated with all-cause hospital transfer (p < 0.05) but not transfers due to infection. Among residents with advanced CHF, integration intensity was not associated with either outcome. Conclusions: NH policies aimed to promote integration of palliative care and infection management may reduce burdensome hospital transfers for residents with advanced dementia. For residents with advanced CHF and COPD, alternative strategies may be needed to promote best practices for infection management at end of life.
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Affiliation(s)
| | - Mansi Agarwal
- Columbia University School of Nursing, New York, New York, USA
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10
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Lyon ME, Caceres S, Scott RK, Benator D, Briggs L, Greenberg I, D'Angelo LJ, Cheng YI, Wang J. Advance Care Planning-Complex and Working: Longitudinal Trajectory of Congruence in End-of-Life Treatment Preferences: An RCT. Am J Hosp Palliat Care 2021; 38:634-643. [PMID: 33530701 DOI: 10.1177/1049909121991807] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
CONTEXT The effect of advance care planning (ACP) interventions on the trajectory of end-of-life treatment preference congruence between patients and surrogate decision-makers is unstudied. OBJECTIVE To identify unobserved distinctive patterns of congruence trajectories and examine how the typology of outcome development differed between ACP and controls. METHODS Multisite, assessor-blinded, intent-to-treat, randomized clinical trial enrolled participants between October 2013 to March 2017 from 5 hospital-based HIV clinics. Persons living with HIV(PLWH)/surrogate dyads were randomized to 2 weekly 60-minute sessions: ACP (1) ACP facilitated conversation, (2) advance directive completion; or Control (1) Developmental/relationship history, (2) Nutrition/Exercise. Growth Mixed Modeling was used for 18-month post-intervention analysis. FINDINGS 223 dyads (N = 449 participants) were enrolled. PLWH were 56% male, aged 22 to 77 years, and 86% African American. Surrogates were 56% female, aged 18 to 82 years, and 84% African American. Two latent classes (High vs. Low) of congruence growth trajectory were identified. ACP influenced the trajectory of outcome growth (congruence in all 5 AIDS related situations) by latent class. ACP dyads had a significantly higher probability of being in the High Congruence latent class compared to controls (52%, 75/144 dyads versus 27%, 17/62 dyads, p = 0.001). The probabilities of perfect congruence diminished at 3-months post-intervention but was then sustained. ACP had a significant effect (β = 1.92, p = 0.006, OR = 7.10, 95%C.I.: 1.729, 26.897) on the odds of being in the High Congruence class. CONCLUSION ACP had a significant effect on the trajectory of congruence growth over time. ACP dyads had 7 times the odds of congruence, compared to controls. Three-months post-intervention is optimal for booster sessions.
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Affiliation(s)
- Maureen E Lyon
- Division of Adolescent and Young Adult Medicine, 571630Children's National Hospital, Washington, District of Columbia (DC), USA.,Center for Translational Research/Children's Research Institute, Washington, DC, USA.,George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Sarah Caceres
- Nova Southeastern University School of Nursing, Fort Lauderdale, FL, USA
| | - Rachel K Scott
- MedStar: Health Research Institute and Washington Hospital Center, Washington, DC, USA
| | - Debra Benator
- Washington DC Veterans Affairs Medical Center, Washington, DC, USA
| | - Linda Briggs
- Respecting Choices, Coalition to Transform Advance Care Innovations, Washington, DC, USA
| | | | - Lawrence J D'Angelo
- Division of Adolescent and Young Adult Medicine, 571630Children's National Hospital, Washington, District of Columbia (DC), USA
| | | | - Jichuan Wang
- Center for Translational Research/Children's Research Institute, Washington, DC, USA.,George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,Division of Biostatistics & Study Methodology, Center for Translational Research/Children's Research Institute, Washington, DC, USA
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11
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Resick JM, Arnold RM, Sudore RL, Farrell D, Belin S, Althouse AD, Ferrell B, Hammes BJ, Chu E, White DB, Rak KJ, Schenker Y. Patient-centered and efficacious advance care planning in cancer: Protocol and key design considerations for the PEACe-compare trial. Contemp Clin Trials 2020; 96:106071. [PMID: 32739493 PMCID: PMC7510772 DOI: 10.1016/j.cct.2020.106071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 06/05/2020] [Accepted: 06/12/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Failure to deliver care near the end of life that reflects the needs, values and preferences of patients with advanced cancer remains a major shortcoming of our cancer care delivery system. METHODS A mixed-methods comparative effectiveness trial of in-person advance care planning (ACP) discussions versus web-based ACP is currently underway at oncology practices in Western Pennsylvania. Patients with advanced cancer and their caregivers are invited to enroll. Participants are randomized to either (1) in-person ACP discussions via face-to-face visits with a nurse facilitator following the Respecting Choices® Conversation Guide or (2) web-based ACP using the PREPARE for your care™ web-based ACP tool. The trial compares the effect of these two interventions on patient and family caregiver outcomes (engagement in ACP, primary outcome; ACP discussions; advance directive (AD) completion; quality of end-of-life (EOL) care; EOL goal attainment; caregiver psychological symptoms; healthcare utilization at EOL) and assesses implementation costs. Factors influencing ACP effectiveness are assessed via in-depth interviews with patients, caregivers and clinicians. DISCUSSION This trial will provide new and much-needed empirical evidence about two patient-facing ACP approaches that successfully overcome limitations of traditional written advance directives but entail very different investments of time and resources. It is innovative in using mixed methods to evaluate not only the comparative effectiveness of these approaches, but also the contexts and mechanisms influencing effectiveness. Data from this study will inform clinicians, payers and health systems seeking to adopt and scale the most effective and efficient ACP strategy in real-world oncology settings.
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Affiliation(s)
- Judith M Resick
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA, 15213, USA.
| | - Robert M Arnold
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA, 15213, USA.
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, USA; San Francisco Veterans Affairs Health Care System, SFVAMC 4150 Clement Street, #151R, San Francisco, CA 94121, USA.
| | - David Farrell
- People Designs, Inc., 1304 Broad Street, Durham, NC 27705, USA.
| | - Shane Belin
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA, 15213, USA.
| | - Andrew D Althouse
- Center for Research on Health Care Data Center, University of Pittsburgh School of Medicine, 200 Meyran Avenue, Suite 300, Pittsburgh, PA 15213, USA.
| | - Betty Ferrell
- Division of Nursing Research and Education, Department of Population Sciences, City of Hope Medical Center, 1500 Duarte Road, Duarte, CA 91010, USA.
| | - Bernard J Hammes
- Respecting Choices, A Division of C-TAC Innovations, PO Box 258, Oregon, WI 53575-0258, USA.
| | - Edward Chu
- Department of Medicine, Division of Hematology-Oncology and Cancer Therapeutics Program, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Douglas B White
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15213, USA.
| | - Kimberly J Rak
- University of Pittsburgh, School of Medicine, Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Program on Ethics and Decision Making, 3520 Fifth Ave, Suite100, Pittsburgh, PA 15213, USA.
| | - Yael Schenker
- Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA, 15213, USA.
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12
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Zhuang Q, Lau ZY, Ong WS, Yang GM, Tan KB, Ong MEH, Wong TH. Sociodemographic and clinical factors for non-hospital deaths among cancer patients: A nationwide population-based cohort study. PLoS One 2020; 15:e0232219. [PMID: 32324837 PMCID: PMC7179880 DOI: 10.1371/journal.pone.0232219] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 04/09/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Factors associated with place of death inform policies with respect to allocating end-of-life care resources and tailoring supportive measures. OBJECTIVE To determine factors associated with non-hospital deaths among cancer patients. DESIGN Retrospective cohort study of cancer decedents, examining factors associated with non-hospital deaths using multinomial logistic regression with hospital deaths as the reference category. SETTING/SUBJECTS Cancer patients (n = 15254) in Singapore who died during the study period from January 1, 2012 till December 31, 2105 at home, acute hospital, long-term care (LTC) or hospice were included. RESULTS Increasing age (categories ≥65 years: RRR 1.25-2.61), female (RRR 1.40; 95% CI 1.28-1.52), Malays (RRR 1.67; 95% CI 1.47-1.89), Brain malignancy (RRR 1.92; 95% CI 1.15-3.23), metastatic disease (RRR 1.33-2.01) and home palliative care (RRR 2.11; 95% CI 1.95-2.29) were associated with higher risk of home deaths. Patients with low socioeconomic status were more likely to have hospice or LTC deaths: those living in smaller housing types had higher risk of dying in hospice (1-4 rooms apartment: RRR 1.13-3.17) or LTC (1-5 rooms apartment: RRR 1.36-4.11); and those with Medifund usage had higher risk of dying in LTC (RRR 1.74; 95% CI 1.36-2.21). Patients with haematological malignancies had increased risk of dying in hospital (categories of haematological subtypes: RRR 0.06-0.87). CONCLUSIONS We found key sociodemographic and clinical factors associated with non-hospital deaths in cancer patients. More can be done to enable patients to die in the community and with dignity rather than in a hospital.
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Affiliation(s)
- Qingyuan Zhuang
- Department of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
- * E-mail:
| | - Zheng Yi Lau
- Policy Research and Evaluation Division, Ministry of Health, Singapore, Singapore
| | - Whee Sze Ong
- National Cancer Centre Singapore, Singapore, Singapore
| | - Grace Meijuan Yang
- Department of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
- Lien Centre for Palliative Care, Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Kelvin Bryan Tan
- Policy Research and Evaluation Division, Ministry of Health, Singapore, Singapore
- Saw Swee Hock School of Public Health, Singapore, Singapore
| | - Marcus Eng Hock Ong
- Singapore General Hospital, Singapore, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Ting Hway Wong
- Singapore General Hospital, Singapore, Singapore
- Duke-National University of Singapore Medical School, Singapore, Singapore
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13
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Carpenter JG, Lam K, Ritter AZ, Ersek M. A Systematic Review of Nursing Home Palliative Care Interventions: Characteristics and Outcomes. J Am Med Dir Assoc 2020; 21:583-596.e2. [PMID: 31924556 DOI: 10.1016/j.jamda.2019.11.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 09/11/2019] [Accepted: 11/20/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Despite recommendations to integrate palliative care into nursing home care, little is known about the most effective ways to meet this goal. OBJECTIVE To examine the characteristics and effectiveness of nursing home interventions that incorporated multiple palliative care domains (eg, physical aspects of care-symptom management, and ethical aspects-advance care planning). DESIGN Systematic review. METHODS We searched MEDLINE via PubMed, Embase, CINAHL, and Cochrane Library's CENTRAL from inception through January 2019. We included all randomized and nonrandomized trials that compared palliative care to usual care and an active comparator. We assessed the type of intervention, outcomes, and the risk of bias. RESULTS We screened 1167 records for eligibility and included 13 articles. Most interventions focused on staff education and training strategies and on implementing a palliative care team. Many interventions integrated advance care planning initiatives into the intervention. We found that palliative care interventions in nursing homes may enhance palliative care practices, including processes to assess and manage pain and symptoms. However, inconsistent outcomes and high or unclear risk of bias among most studies requires results to be interpreted with caution. CONCLUSIONS AND IMPLICATIONS Heterogeneity in methodology, findings, and study bias within the existing literature revealed limited evidence for nursing home palliative care interventions. Findings from a small group of diverse clinical trials suggest that interventions enhanced nursing home palliative care and improved symptom assessment and management processes.
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Affiliation(s)
- Joan G Carpenter
- University of Pennsylvania School of Nursing, Philadelphia, PA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA.
| | - Karissa Lam
- University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Ashley Z Ritter
- University of Pennsylvania National Clinician Scholars Program, Philadelphia, PA
| | - Mary Ersek
- University of Pennsylvania School of Nursing, Philadelphia, PA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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14
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Mathew C, Hsu AT, Prentice M, Lawlor P, Kyeremanteng K, Tanuseputro P, Welch V. Economic evaluations of palliative care models: A systematic review. Palliat Med 2020; 34:69-82. [PMID: 31854213 DOI: 10.1177/0269216319875906] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Palliative care aims to improve quality of life by relieving physical, emotional, and spiritual suffering. Health system planning can be informed by evaluating cost and effectiveness of health care delivery, including palliative care. AIM The objectives of this article were to describe and critically appraise economic evaluations of palliative care models and to identify cost-effective models in improving patient-centered outcomes. DESIGN We conducted a systematic review and registered our protocol in PROSPERO (CRD42016053973). DATA SOURCES A systematic search of nine medical and economic databases was conducted and extended with reference scanning and gray literature. Methodological quality was assessed using the Drummond checklist. RESULTS We identified 12,632 articles and 5 were included. We included two modeling studies from the United States and England, and three economic evaluations from England, Australia, and Italy. Two studies compared home-based palliative care models to usual care, and one compared home-based palliative care to no care. Effectiveness outcomes included hospital readmission prevented, days at home, and palliative care symptom severity. All studies concluded that palliative care was cost-effective compared to usual care. The methodological quality was good overall, but three out of five studies were based on small sample sizes. CONCLUSION Applicability and generalizability of evidence is uncertain due to small sample sizes, short duration, and limited modeling of costs and effects. Further economic evaluations with larger sample sizes are needed, inclusive of the diversity and complexity of palliative care populations and using patient-centered outcomes.
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Affiliation(s)
| | - Amy T Hsu
- Bruyère Research Institute, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Insitute, Ottawa, ON, Canada.,Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Michelle Prentice
- Bruyère Research Institute, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Insitute, Ottawa, ON, Canada
| | - Peter Lawlor
- Bruyère Research Institute, Ottawa, ON, Canada.,Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Kwadwo Kyeremanteng
- Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,Institut du Savoir Montfort, Ottawa, ON, Canada
| | - Peter Tanuseputro
- Bruyère Research Institute, Ottawa, ON, Canada.,Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Vivian Welch
- Bruyère Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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15
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Overbeek A, Polinder S, Haagsma J, Billekens P, de Nooijer K, Hammes BJ, Muliaditan D, van der Heide A, Rietjens JA, Korfage IJ. Advance Care Planning for frail older adults: Findings on costs in a cluster randomised controlled trial. Palliat Med 2019; 33:291-300. [PMID: 30269650 DOI: 10.1177/0269216318801751] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Advance Care Planning aims at improving alignment of care with patients’ preferences. This may affect costs of medical care. Aim: To determine the costs of an Advance Care Planning programme and its effects on the costs of medical care and on concordance of care with patients’ preferences. Design/settings/participants: In a cluster randomised trial, 16 residential care homes were randomly allocated to the intervention group, where frail, older participants were offered facilitated Advance Care Planning conversations or to the control group. We calculated variable costs of Advance Care Planning per participant including personnel and travel costs of facilitators. Furthermore, we assessed participants’ healthcare use during 12 months applying a broad perspective (including medical care, inpatient days in residential care homes, home care) and calculated costs of care per participant. Finally, we investigated whether treatment goals were in accordance with preferences. Analyses were conducted for 97 participants per group. Trial registration number: NTR4454. Results: Average variable Advance Care Planning costs were €76 per participant. The average costs of medical care were not significantly different between the intervention and control group (€2360 vs €2235, respectively, p = 0.36). Costs of inpatient days in residential care homes (€41,551 vs €46,533) and of home care (€14,091 vs €17,361) were not significantly different either. Concordance of care with preferences could not be assessed since treatment goals were often not recorded. Conclusion: The costs of an Advance Care Planning programme were limited. Advance Care Planning did not significantly affect the costs of medical care for frail older adults.
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Affiliation(s)
- Anouk Overbeek
- 1 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Suzanne Polinder
- 1 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Juanita Haagsma
- 1 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | | | - Kim de Nooijer
- 1 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | | | - Daniel Muliaditan
- 1 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | | | | | - Ida J Korfage
- 1 Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
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16
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Ng CWL, Cheong SK, Govinda Raj A, Teo W, Leong I. End-of-life care preferences of nursing home residents: Results of a cross-sectional study. Palliat Med 2016; 30:843-53. [PMID: 26962065 DOI: 10.1177/0269216316634242] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Palliative care services were not available in nursing homes in Singapore. Project CARE (Care At the end-of-life for Residents in homes for the Elderly) was a pilot programme that aimed to promote advance care planning and improve end-of-life care in nursing homes. AIM We aimed to examine end-of-life care preferences among nursing home residents, and identify factors associated with preference for medical intervention, cardiopulmonary resuscitation and place of death. DESIGN AND SETTING/PARTICIPANTS A cross-sectional study using data from advance care planning discussions was conducted from September 2009 to April 2012 across seven nursing homes. The advance care planning discussion was conducted with the resident (with a prognosis of 6 months or 1 year), their families and staff from the nursing home and hospital. RESULTS A total of 600 residents and their families completed the advance care planning discussion. Majority (93.2%) preferred not to proceed with cardiopulmonary resuscitation, 52.3% opted for limited additional intervention at the nursing home with escalation to the hospital if necessary and 77.0% preferred to die at the nursing home. Residents 85+ years (relative risk ratio: 3.34, 95% confidence interval: 1.13-9.93, p = 0.030) were more likely to prefer medical intervention at the nursing home only. No associations were found with the preference for cardiopulmonary resuscitation. Residents who were single, or who were Christians or Catholics (adjusted odds ratio: 2.09, 95% confidence interval: 1.04-4.19, p = 0.039), were more likely to prefer to die at the nursing home. CONCLUSION Preferences for medical interventions in nursing homes provide support to extend palliative care services to nursing homes, which may benefit residents who are older, single, or Christians or Catholics.
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Affiliation(s)
- Charis Wei Ling Ng
- Health Services & Outcomes Research, National Healthcare Group, Singapore
| | - S K Cheong
- Continuing and Community Care Department, Tan Tock Seng Hospital, Singapore
| | - A Govinda Raj
- Health Services & Outcomes Research, National Healthcare Group, Singapore
| | - Wsk Teo
- Health Services & Outcomes Research, National Healthcare Group, Singapore
| | - Iyo Leong
- Continuing and Community Care Department, Tan Tock Seng Hospital, Singapore
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17
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Economic (gross cost) analysis of systematically implementing a programme of advance care planning in three Irish nursing homes. BMC Res Notes 2016; 9:237. [PMID: 27112921 PMCID: PMC4845350 DOI: 10.1186/s13104-016-2048-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 04/18/2016] [Indexed: 11/10/2022] Open
Abstract
Background Although advance care planning (ACP) and the use of advanced care directives (ACD) and end-of-life care plans are associated with a reduction in inappropriate hospitalisation, there is little evidence supporting the economic benefits of such programmes. We assessed the economic impact (gross savings) of the Let Me Decide (LMD) ACP programme in Ireland, specifically the impact on hospitalisations, bed days and location of resident deaths, before and after systematic implementation of the LMD-ACP combined with a palliative care education programme. Methods The LMD-ACP was introduced into three long-term care (LTC) facilities in Southern Ireland and outcomes were compared pre and post implementation. In addition, 90 staff were trained in a palliative care educational programme. Economic analysis including probabilistic sensitivity analysis was performed. Results The uptake of an ACD or end-of-life care post-implementation rose from 25 to 76 %. Post implementation, there were statistically significant decreases in hospitalisation rates from baseline (hospitalisation incidents declined from 27.8 to 14.6 %, z = 3.96, p < 0.001; inpatient hospital days reduced from 0.54 to 0.36 %, z = 8.85, p < 0.001). The percentage of hospital deaths also decreased from 22.9 to 8.4 %, z = 3.22, p = 0.001. However, length of stay (LOS) increased marginally (7–9 days). Economic analysis suggested a cost-reduction related to reduced hospitalisations ranging between €10 and €17.8 million/annum and reduction in ambulance transfers, estimated at €0.4 million/annum if these results were extrapolated nationally. When unit costs and LOS estimates were varied in scenario analyses, the expected cost reduction owing to reduced hospitalisations, ranged from €17.7 to €42.4 million nationally. Conclusions Implementation of the LMD-ACP (ACD/end-of-life care plans combined with palliative care education) programme resulted in reduced rates of hospitalisation. Despite an increase in LOS, likely reflecting more complex care needs of admitted residents, gross costs were reduced and scenario analysis projected large annual savings if these results were extrapolated to the wider LTC population in Ireland.
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18
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Martin RS, Hayes B, Gregorevic K, Lim WK. The Effects of Advance Care Planning Interventions on Nursing Home Residents: A Systematic Review. J Am Med Dir Assoc 2016; 17:284-93. [DOI: 10.1016/j.jamda.2015.12.017] [Citation(s) in RCA: 133] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 12/16/2015] [Indexed: 10/22/2022]
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19
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Dixon J, Matosevic T, Knapp M. The economic evidence for advance care planning: Systematic review of evidence. Palliat Med 2015; 29:869-84. [PMID: 26060176 DOI: 10.1177/0269216315586659] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Advance care planning is a process of discussion and review concerning future care in the event of losing capacity. Aimed at improving the appropriateness and quality of care, it is also often considered a means of making better use of healthcare resources at the end of life. AIM To review and summarise economic evidence on advance care planning. DESIGN A systematic review of the academic literature. DATA SOURCES We searched for English language, peer-reviewed journal articles, 1990-2014, using relevant research databases: PubMed, ProQuest, CINAHL Plus with Full Text; EconLit, PsycINFO, SocINDEX with Full Text and International Bibliography of the Social Sciences. Empirical studies using statistical methods in which advance care planning and costs are variables were included. RESULTS There are no published cost-effectiveness studies. Included studies focus on healthcare savings, usually associated with reduced demand for hospital care. Advance care planning appears to be associated with healthcare savings for some people in some circumstances, such as people living with dementia in the community, people in nursing homes or in areas with high end-of-life care spending. There is no evidence that advance care planning is likely to be more expensive. CONCLUSION There is need for clearer articulation of the likely mechanisms by which advance care planning can lead to reduced care costs or improved cost-effectiveness, particularly for people who retain capacity. There is also a need to consider wider costs, including the costs of advance care planning facilitation or interventions and the costs of substitute health, social and informal care. Economic outcomes need to be considered in the context of quality benefits.
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Affiliation(s)
- Josie Dixon
- Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science (LSE), London, UK
| | - Tihana Matosevic
- Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science (LSE), London, UK
| | - Martin Knapp
- Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science (LSE), London, UK
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20
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Variation in the costs of dying and the role of different health services, socio-demographic characteristics, and preceding health care expenses. Soc Sci Med 2014; 120:110-7. [PMID: 25238558 DOI: 10.1016/j.socscimed.2014.09.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 08/20/2014] [Accepted: 09/09/2014] [Indexed: 01/03/2023]
Abstract
The health care costs of population ageing are for an important part attributable to higher mortality rates in combination with high costs of dying. This paper answers three questions that remain unanswered regarding the costs of dying: (1) contributions of different health services to the costs of dying; (2) variation in the costs of dying; and (3) the influence of preceding health care expenses on the costs of dying. We retrieved data on 61,495 Dutch subjects aged 65 and older from July 2007 through 2010 from a regional health care insurer. We included all deceased subjects of whom health care expenses were known for 26 months prior to death (n=2833). Costs of dying were defined as health care expenses made in the last six months before death. Lorenz curves, generalized linear models and a two-part model were used for our analyses. (1) The average costs of dying are €25,919. Medical care contributes to 57% of this total, and long-term care 43%. The costs of dying mainly relate to hospital care (40%). (2) In the costs of dying, 75% is attributable to the costliest half of the population. For medical care, this distribution figure is 86%, and for long-term care 92%. Age and preceding expenses are significant determinants of this variation in the costs of dying. (3) Overall, higher preceding health care expenses are associated with higher costs of dying, indicating that the costs of dying are higher for those with a longer patient history. To summarize, there is not a large variation in the costs of dying, but there are large differences in the nature of these costs. Before death, the oldest old utilize more long-term care while their younger counterparts visit hospitals more often. To curb the health care costs of population ageing, a further understanding of the costs of dying is crucial.
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