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Alias R, Neo YL, Wang L, Sie LZ, Goh HJ, Mohamed Hussein MY, Abdullah H, Wong YP. Fulfilling last wishes: improving the compassionate discharge process. BMJ Open Qual 2024; 13:e002666. [PMID: 39009462 PMCID: PMC11253726 DOI: 10.1136/bmjoq-2023-002666] [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: 10/30/2023] [Accepted: 06/29/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND Compassionate discharges (ComD), commonly known as rapid discharges, are urgent one-way discharges for critically ill hospitalised patients with death expected within hours or less than 7 days, to die at their place of choice-usually in their own home. Challenges abound in this time-sensitive setting when multiple parties must work together to prepare medically unstable patients for discharge, yet healthcare staff are largely unaware of the process, resulting in delays. METHODS Process mapping, an Ishikawa diagram and a Pareto chart were used to identify barriers, which included timely acquisition of home equipment and medication and poor communication among stakeholders. In May 2020, the Quality Improvement (QI) team embarked on a pilot project to reduce family caregiver anxiety and delays in the ComD process while maintaining a success rate above 90% over a 12-month period. INTERVENTIONS Three Plan-Do-Study-Act (PDSA) cycles were used to refine a ComD resource package that was developed; this consisted of a checklist, a kit and caregiver resources. This was to support nurses, doctors and families during this difficult and emotional transition. Items in the ComD resource package were revised iteratively based on user feedback, with further data collected to measure its usefulness. RESULTS The 12-month ComD success rate over 3 PDSA cycles were 88.9%, 94.2% and 96.7%, respectively, after each cycle. There was a consistent reduction in the level of family anxiety before and after caregiver training and resources. Reasons for failed ComD included acute clinical deterioration or delays in obtaining home oxygen support. CONCLUSION The ComD resource package allowed collaborative work across different disciplines, strengthening the safety and utility of ComD and allowing patients to die in their place of choice. These are ubiquitous across settings; this QI problem is thus relevant beyond our local institution.
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Affiliation(s)
- Rasidah Alias
- Specialty Nursing, Changi General Hospital, Singapore
| | - Yi Ling Neo
- Specialty Nursing, Changi General Hospital, Singapore
| | - Liyun Wang
- Advanced Practice Nurse Development, Changi General Hospital, Singapore
| | - Long Zhen Sie
- Specialty Nursing, Changi General Hospital, Singapore
| | - Hwee Jin Goh
- Specialty Nursing, Changi General Hospital, Singapore
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Bayani DB, Lin YC, Nagarajan C, Ooi MG, Tso ACY, Cairns J, Wee HL. Modeling First-Line Daratumumab Use for Newly Diagnosed, Transplant-Ineligible, Multiple Myeloma: A Cost-Effectiveness and Risk Analysis for Healthcare Payers. PHARMACOECONOMICS - OPEN 2024:10.1007/s41669-024-00503-9. [PMID: 38900407 DOI: 10.1007/s41669-024-00503-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/03/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND AND OBJECTIVE This study aimed to assess the cost-effectiveness of two regimens regarded as the standard of care for the treatment of newly diagnosed, transplant-ineligible multiple myeloma in Singapore: (1) daratumumab, lenalidomide, and dexamethasone and (2) bortezomib, lenalidomide, and dexamethasone. Additionally, it aimed to explore potential strategies to manage decision uncertainty and mitigate financial risk. METHODS A cost-effectiveness analysis from the healthcare system perspective was conducted using a partitioned survival model to estimate lifetime costs and quality-adjusted life years (QALYs) associated with daratumumab-based treatment and the bortezomib-based regimen. The analysis used data from the MAIA and SWOG S0777 trials and incorporated local real-world data where available. Sensitivity analyses were performed to evaluate the robustness of the findings, and a risk analysis was conducted to analyze various payer strategies in terms of their payer strategy and uncertainty burden (P-SUB), which account for the decision uncertainty and the additional cost of choosing a suboptimal intervention. RESULTS The incremental cost-effectiveness ratio (ICER) for daratumumab, lenalidomide, and dexamethasone (DRd) compared with bortezomib, lenalidomide, and dexamethasone (VRd) was US $90,364 per QALY gained. The results were sensitive to variations in survival for DRd, postprogression treatment costs, cost of hospice care, and hazard ratio for progression-free survival. The scenarios explored indicated that structural assumptions, such as the time horizon of the analysis, significantly influenced the results due to uncertainties arising from immature trial data and treatment efficacy over time. Among the various payer strategies compared, an upfront price discount for daratumumab emerged as the best approach with the lowest P-SUB at US $14,708. CONCLUSION In conclusion, this study finds that daratumumab as a first-line treatment for myeloma exceeds the cost-effectiveness threshold considered in this evaluation. An upfront price reduction is the recommended strategy to manage uncertainties and mitigate financial risks. These findings highlight the importance of targeted payer strategies to address specific types and sources of uncertainty.
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Affiliation(s)
- Diana Beatriz Bayani
- Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building, 12 Science Drive 2, Singapore, 117549, Republic of Singapore.
| | - Yihao Clement Lin
- Department of Hematology, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Melissa G Ooi
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | | | - John Cairns
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Hwee Lin Wee
- Saw Swee Hock School of Public Health, Department of Pharmacy, National University of Singapore, Singapore, Singapore
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Ozdemir S, Chaudhry I, Malhotra C, Teo I, Finkelstein EA. Goals of Care Among Patients With Advanced Cancer and Their Family Caregivers in the Last Years of Life. JAMA Netw Open 2024; 7:e245866. [PMID: 38602677 PMCID: PMC11009823 DOI: 10.1001/jamanetworkopen.2024.5866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 02/13/2024] [Indexed: 04/12/2024] Open
Abstract
Importance Understanding goals of care for terminally ill patients at the end of life is crucial to ensure that patients receive care consistent with their preferences. Objectives To investigate the patterns of goals of care among patient-caregiver dyads over the last years of the patient's life and the associations of the goals of care with patient-caregiver characteristics. Design, Setting, and Participants This prospective cohort study of 210 patient-caregiver dyads involved surveys every 3 months from July 8, 2016, until the patient's death or February 28, 2022. Data from the last 2 years of the patients' lives were analyzed. Dyads, which comprised patients with stage IV solid cancer and their caregivers, were recruited from outpatient clinics at 2 major cancer centers in Singapore. Main Outcomes and Measures Goals of care were examined via the tradeoffs between life extension and symptom management and between life extension and cost containment. The actor-partner interdependence framework was implemented using mixed-effects linear regressions. Results This study included 210 dyads (patients: mean [SD] age, 62.6 [10.5] years; 108 men [51.4%]; caregivers: mean [SD] age, 49.4 [14.6] years; 132 women [62.9%]). On average, 34% of patients (264 of 780 observations; range, 23%-42%) and 29% of caregivers (225 of 780 observations; range, 20%-43%) prioritized symptom management over life extension, whereas 24% of patients (190 of 780 observations; range, 18%-32%) and 19% of caregivers (148 of 780 observations; range, 8%-26%) prioritized life extension. Between cost containment and life extension, on average, 28% of patients (220 of 777 observations; range, 22%-38%) and 17% of caregivers (137 of 780 observations; range, 10%-25%) prioritized cost containment, whereas 26% of patients (199 of 777 observations; range, 18%-34%) and 35% of caregivers (271 of 780 observations; range, 25%-45%) prioritized life extension. Goals of care did not change as patients approached death. Patients prioritized symptom management if they experienced higher symptom burden (average marginal effect [SE], 0.04 [0.01]), worse spiritual well-being (average marginal effect [SE], -0.04 [0.01]), and accurate (vs inaccurate) prognostic awareness (average marginal effect [SE], 0.40 [0.18]) and if their caregivers reported accurate prognostic awareness (average marginal effect [SE], 0.53 [0.18]), lower impact of caregiving on finances (average marginal effect [SE], -0.28 [0.08]), and poorer caregiving self-esteem (average marginal effect [SE], -0.48 [0.16]). Compared with patients, caregivers expressed lower preferences for cost containment (average marginal effect [SE], -0.63 [0.09]). Patients prioritized cost containment if they were older (average marginal effect [SE], 0.03 [0.01]), had higher symptom burden (average marginal effect [SE], 0.04 [0.01]), had poorer spiritual well-being (average marginal effect [SE], -0.04 [0.01]), and their caregivers reported poorer caregiving self-esteem (average marginal effect [SE], -0.51 [0.16]) and more family support (average marginal effect [SE], -0.30 [0.14]). Conclusions and Relevance In this cohort study of patient-caregiver dyads, findings suggested the importance of interventions aimed at reducing discordance in goals of care between patients and caregivers and helping them develop realistic expectations to avoid costly, futile treatments.
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Affiliation(s)
- Semra Ozdemir
- Lien Centre for Palliative Care, Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
- Department of Population Health Sciences, Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Isha Chaudhry
- Lien Centre for Palliative Care, Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
| | - Chetna Malhotra
- Lien Centre for Palliative Care, Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
| | - Irene Teo
- Lien Centre for Palliative Care, Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
- Department of Psychosocial Oncology, National Cancer Centre, Singapore
| | - Eric Andrew Finkelstein
- Lien Centre for Palliative Care, Signature Programme in Health Services and System Research, Duke-NUS Medical School, Singapore
- Department of Population Health Sciences, Duke Clinical Research Institute, Duke University, Durham, North Carolina
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
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Balasubramanian I, Malhotra C. Why is end-of-life inpatient cost high among cancer patients? A prospective cohort study. Cancer Med 2024; 13:e7057. [PMID: 38457240 PMCID: PMC10923043 DOI: 10.1002/cam4.7057] [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: 10/30/2023] [Revised: 01/23/2024] [Accepted: 02/16/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Inpatient cost for cancer patients is high during the last year of life, but reasons for this are not understood. We aim to understand the type of hospital admissions and inpatient services associated with an increase in inpatient cost in last year of life. METHODS We used survey and billing records of 439 deceased patients with a solid metastatic cancer, enrolled in a prospective cohort study. Based on cost per day of inpatient admissions, we classified admissions as low- or high-intensity. We decomposed the inpatient cost into cost for different inpatient services. We examined the inpatient cost in the last year of life. We also assessed patient characteristics associated with higher inpatient cost in the next 3 months. RESULTS Towards death, proportion of inpatient cost for "maintenance care" increased while that for intensive care unit (ICU) and surgeries decreased. Low-intensity, compared to high-intensity admissions had a higher proportion of cost for "maintenance care" and a lower proportion for surgeries and ICU. Number of low-intensity admissions increased more steeply towards death than high-intensity admissions. Both admission types contributed equally to the share of inpatient cost. Older patients were less likely to have a high-intensity admission (β:-0.01, CI: -0.02, 0.00). Greater preference for life extension (β: 0.06, CI: 0.01, 0.11) and inaccurate prognostic belief were associated with higher cost of high-intensity admissions (β: 0.32, CI: 0.03, 0.62). CONCLUSIONS Findings suggest that inpatient costs in last year of life may be reduced if maintenance care is availed in low-cost settings such as hospice/palliative care alongside steps to reduce non-beneficial surgeries and ICU admissions.
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Affiliation(s)
| | - Chetna Malhotra
- Lien Centre for Palliative Care, Duke‐NUS Medical SchoolSingaporeSingapore
- Program in Health Services and Systems Research, Duke‐NUS Medical SchoolSingaporeSingapore
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Ul Hassan SS, Ali W, Khan H, Raja AR, Hassan M, Haque G, Ayub F, Waqar MA, Latif A. Confronted With Death: Factors Affecting End of Life Decisions in the Intensive Care Unit. OMEGA-JOURNAL OF DEATH AND DYING 2023:302228231198360. [PMID: 37632273 DOI: 10.1177/00302228231198360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Abstract
To determine how often care is limited at the end of life and the factors that are associated with this decision, we reviewed the medical records of all patients that passed away in the intensive care units (ICU) of Aga Khan University. We found that a majority of patients had Do-Not-Resuscitate orders in place at the time of death. Our analysis yielded 6 variables that were associated with the decision to limit care. These are patient age, sex, duration of mechanical ventilation, Glasgow Coma Scale (GCS) ≤8 at any point during ICU stay, GCS ≤8 in the first 24 hours following ICU admission, and mean arterial pressure <65 mm of Hg while on vasopressors in the first 24 hours following ICU admission. These variables require further study and should be carefully considered during end of life discussions to allow for optimal management at the end of life.
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Affiliation(s)
| | - Wajid Ali
- Dean's Clinical Research Fellow, Aga Khan University, Karachi, Pakistan
| | - Hamza Khan
- Dean's Clinical Research Fellow, Aga Khan University, Karachi, Pakistan
| | | | | | - Ghazal Haque
- Centre for Patient Safety, Aga Khan University, Karachi, Pakistan
| | - Farwa Ayub
- Centre for Patient Safety, Aga Khan University, Karachi, Pakistan
| | | | - Asad Latif
- Centre for Patient Safety, Aga Khan University, Karachi, Pakistan
- Department of Anesthesiology, Aga Khan University Hospital, Karachi, Pakistan
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, USA
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Malhotra C, Balasubramanian I. Caregivers' End-of-Life Care Goals for Persons with Severe Dementia Change Over Time. J Alzheimers Dis 2023:JAD221161. [PMID: 37125548 DOI: 10.3233/jad-221161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
BACKGROUND Family caregivers make end-of-life (EOL) decisions for persons with severe dementia (PWSDs). It is not known whether the family caregivers' goals change over time. OBJECTIVE Assess caregivers' EOL care goal for PWSDs and change in these goals over time. METHODS Using a prospective cohort of 215 caregivers of PWSDs, we assessed the proportion of caregivers whose EOL care goal for PWSDs changed between two consecutive time points. Mixed effects multinomial regression models assessed factors associated with caregivers' EOL care goals for PWSD (maximal, moderate, minimal life extension); and change in EOL care goal from previous time point. RESULTS At baseline, 20% of the caregivers had a goal of maximal life extension for their PWSD, and 59% changed their EOL care goal at least once over a period of 16 months. Caregivers of PWSDs with lower quality of life (RR: 1.15, CI: 1.06, 1.24), who expected shorter life expectancy for PWSDs (RR: 10.34, CI: 2.14, 49.99) and who had an advance care planning discussion (RR: 3.52, CI: 1.11, 11.18) were more likely to have a goal of minimal life extension for PWSD. Caregivers with higher anticipatory grief (RR: 0.96, CI: 0.93,1) were more likely to have a goal of maximal life extension. Change in PWSDs' quality of life and change in caregivers' anticipatory grief were associated with change in caregivers' EOL care goals. CONCLUSION Caregivers' EOL care goals for PWSDs change over time with change in PWSD and caregiver related factors. Findings have implications regarding how health care providers can engage with caregivers.
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Affiliation(s)
- Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
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Balasubramanian I, Finkelstein E, Malhotra R, Ozdemir S, Malhotra C. Healthcare Cost Trajectories in the Last 2 Years of Life Among Patients With a Solid Metastatic Cancer: A Prospective Cohort Study. J Natl Compr Canc Netw 2022; 20:997-1004.e3. [PMID: 36075386 DOI: 10.6004/jnccn.2022.7038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/24/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Most studies describe the "average healthcare cost trend" among patients with cancer. We aimed to delineate heterogeneous trajectories of healthcare cost during the last 2 years of life of patients with a metastatic cancer and to assess the associated sociodemographic and clinical characteristics and healthcare use. PATIENTS AND METHODS We analyzed a sample of 353 deceased patients from a cohort of 600 with a solid metastatic cancer in Singapore, and we used group-based trajectory modeling to identify trajectories of total healthcare cost during the last 2 years of life. RESULTS The average cost trend showed that mean monthly healthcare cost increased from SGD $3,997 during the last 2 years of life to SGD $7,516 during the last month of life (USD $1 = SGD $1.35). Group-based trajectory modeling identified 4 distinct trajectories: (1) low and steadily decreasing cost (13%); (2) steeply increasing cost in the last year of life (14%); (3) high and steadily increasing cost (57%); and (4) steeply increasing cost before the last year of life (16%). Compared with the low and steadily decreasing cost trajectory, patients with private health insurance (β [SE], 0.75 [0.37]; P=.04) and a greater preference for life extension (β [SE], -0.14 [0.07]; P=.06) were more likely to follow the high and steadily increasing cost trajectory. Patients in the low and steadily decreasing cost trajectory were most likely to have used palliative care (62%) and to die in a hospice (27%), whereas those in the steeply increasing cost before the last year of life trajectory were least likely to have used palliative care (14%) and most likely to die in a hospital (75%). CONCLUSIONS The study quantifies healthcare cost and shows the variability in healthcare cost trajectories during the last 2 years of life. Policymakers, clinicians, patients, and families can use this information to better anticipate, budget, and manage healthcare costs.
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Affiliation(s)
| | - Eric Finkelstein
- Lien Centre for Palliative Care.,Program in Health Services and Systems Research, and
| | - Rahul Malhotra
- Program in Health Services and Systems Research, and.,Centre for Ageing Research and Education, Duke-NUS Medical School, Singapore
| | - Semra Ozdemir
- Lien Centre for Palliative Care.,Program in Health Services and Systems Research, and
| | - Chetna Malhotra
- Lien Centre for Palliative Care.,Program in Health Services and Systems Research, and
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Kaur P, Wu HY, Hum A, Heng BH, Tan WS. Medical cost of advanced illnesses in the last-year of life-retrospective database study. Age Ageing 2022; 51:6406695. [PMID: 34673931 DOI: 10.1093/ageing/afab212] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE This study aims to quantify medical care utilisation, and to describe the cost trajectories of individuals with advanced illnesses in the last-year of life, differentiated by advanced cancer, end-stage organ failure and progressive neurological disorders. METHODS This retrospective database study included decedents who had previous inpatient or outpatient encounters at a public hospital in Singapore. Patients with advanced diseases were identified based on diagnostic codes and clinical criteria. Using a look-back approach, the amount of healthcare services utilised and the corresponding mean monthly and annual costs to the healthcare system in the last 12-months of life were quantified. RESULTS The last 12-months of life among 6,598 decedents was associated with £20,524 (95% confidence interval: £20,013-£21,036) in medical costs, of which 80% was accounted for by inpatient admissions. Costs increased sharply in the last 2-months of life, with a large proportion of monthly costs accounted for by inpatient admissions which rose rapidly from 61% at 12-months prior to death to 94% in the last-month of life. Compared to patients with cancer, individuals diagnosed with non-cancer advanced illnesses accumulated 1.6 times more healthcare costs in the last-year of life with significant differences across patients with end-stage organ failure and progressive neurological disorders. CONCLUSION Healthcare costs varied across disease conditions at the end-of-life. With advance care planning and close collaboration between the inpatient clinical team and the community providers, it may be possible to re-direct some of the hospitalisation costs to community-based palliative care services.
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Affiliation(s)
- Palvinder Kaur
- Health Services and Outcomes Research Department, National Healthcare Group, Singapore 138543
| | - Huei Yaw Wu
- Department of Palliative Medicine, Tan Tock Seng Hospital Singapore, Singapore 308433
- Palliative Care Centre for Excellence in Research and Education, Singapore 308436
| | - Allyn Hum
- Department of Palliative Medicine, Tan Tock Seng Hospital Singapore, Singapore 308433
- Palliative Care Centre for Excellence in Research and Education, Singapore 308436
| | - Bee Hoon Heng
- Health Services and Outcomes Research Department, National Healthcare Group, Singapore 138543
| | - Woan Shin Tan
- Health Services and Outcomes Research Department, National Healthcare Group, Singapore 138543
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