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Fischer C, Bednarz D, Simon J. Methodological challenges and potential solutions for economic evaluations of palliative and end-of-life care: A systematic review. Palliat Med 2024; 38:85-99. [PMID: 38142280 PMCID: PMC10798028 DOI: 10.1177/02692163231214124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2023]
Abstract
BACKGROUND Given the increasing demand for palliative and end-of-life care, along with the introduction of costly new treatments, there is a pressing need for robust evidence on value. However, comprehensive guidance is missing on methods for conducting economic evaluations in this field. AIM To identify and summarise existing information on methodological challenges and potential solutions/recommendations for economic evaluations of palliative and end-of-life care. DESIGN We conducted a systematic review of publications on methodological considerations for economic evaluations of adult palliative and end-of-life care as per our PROSPERO protocol CRD42020148160. Following initial searches, we conducted a two-stage screening process and quality appraisal. Information was thematically synthesised, coded, categorised into common themes and aligned with the items specified in the Consolidated Health Economic Evaluation Reporting Standards statement. DATA SOURCES The databases Medline, Embase, HTADatabase, NHSEED and grey literature were searched between 1 January 1999 and 5 June 2023. RESULTS Out of the initial 6502 studies, 81 were deemed eligible. Identified challenges could be grouped into nine themes: ambiguous and inaccurate patient identification, restricted generalisability due to poor geographic transferability of evidence, narrow costing perspective applied, difficulties defining comparators, consequences of applied time horizon, ambiguity in the selection of outcomes, challenged outcome measurement, non-standardised measurement and valuation of costs as well as challenges regarding a reliable preference-based outcome valuation. CONCLUSION Our review offers a comprehensive context-specific overview of methodological considerations for economic evaluations of palliative and end-of-life care. It also identifies the main knowledge gaps to help prioritise future methodological research specifically for this field.
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Affiliation(s)
- Claudia Fischer
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Damian Bednarz
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Judit Simon
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute Applied Diagnostics, Vienna, Austria
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Nelson KA, Walsh D. The business of palliative medicine—Part 3: The development of a palliative medicine program in an academic medical center. Am J Hosp Palliat Care 2016; 20:345-52. [PMID: 14529037 DOI: 10.1177/104990910302000508] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Palliative medicine is the total continuing care of patients with cancer. Most resources for cancer care focus on curative attempts while often ignoring the symptoms created by the disease and its treatment. Attempts at curative treatment of the malignancy must be coupled with pain and symptom relief, psychosocial and spiritual care, and support for the patient and family extending from the time of diagnosis through the bereavement period. To accomplish this important goal, we must establish comprehensive palliative medicine programs in cancer centers throughout the world. These programs must include education, research, and patient care and must work through an interdisciplinary team. The Cleveland Clinic Foundation palliative medicine program (PMP) is composed of a primary inpatient service, consult service, outpatient clinic, hospice homecare, and cancer homecare services. In this article, we describe the structure and development of the program and suggest future avenues for growth.
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Affiliation(s)
- Kristine A Nelson
- Cancer Treatment Research Foundation, Arlington Heights, Illinois, USA
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Abstract
Defining financial parameters of palliative care (PC) is important for providing sustainable programming. In our study, we evaluated hospital length of stay (LOS) and charges for the first 164 inpatient PC consultations performed by the Advanced Illness Assistance (AIA) team at Blount Memorial Hospital (BMH). These AIA patients had a median LOS of 11 days (range, 3-114 days), mean total charges per patient of $65,795, and mean daily charges of $3,809. Higher mean daily charges (p = 2.74 E-08, chi-square) were associated with patients who received consultation because of nonphysical symptom reasons. Patients were followed in PC consultation (AIA follow-up days) for a median of five days (range, 1-48), and had mean daily charges of $3,117. These mean daily charges were $414 less than the charges for the five days prior to PC consultation (pre-AIA days) (p = 0.04, t-test). There was a significant decrease in laboratory and imaging charges during AIA follow-up (p = 0.04, t-test). The study included a reference group of patients whose information was obtained retrospectively from the BMH Atlas ® (MediQual, Marlborough, MA) database. These reference group patients were hospitalized at BMH during the same time, but they were not seen by the AIA team. The reference group was matched by Diagnosis Related Group (DRG), Admission Severity Grade (ASG), and disposition to the AIA patients. The Atlas patients had a shorter median LOS of six days (range, 1-105 days), and significantly greater mean daily charges of $4,105 (p = 0.006, t-test) compared with AIA patients. Mean daily charges decreased for Atlas patients, as their day of discharge approached (p < 0.001). Estimates of potential charge savings were calculated in two ways: 1) by evaluating the effect of decreasing the LOS of Atlas patients with long LOS (more than seven days) to the level of AIA patients with long LOS, and 2) by comparing the actual mean patient charges during AIA follow-up with using the pre-AIA mean daily charges during the AIA follow-up period and correcting for the effect of decreasing charges that occurred as discharge approached. The estimated savings achieved by decreasing long LOS were more than $100,000 per year, and estimated savings achieved using AIA follow-up charges were more than $1,801,930 per year.
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Affiliation(s)
- John D Cowan
- Palliative Care Service, Advanced Illness Assistance Team, Blount Memorial Hospital, Maryville, Tennessee, USA
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Walsh D. The business of palliative medicine—Part 4: Potential impact of an acute-care palliative medicine inpatient unit in a tertiary care cancer center. Am J Hosp Palliat Care 2016; 21:217-21. [PMID: 15188922 DOI: 10.1177/104990910402100312] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In this study, a hematology/oncology computerized discharge database was qualitatively and quantitatively reviewed using an empirical methodology. The goal was to identify potential patients for admission to a planned acute-care, palliative medicine inpatient unit. Patients were identified by the International Classifications of Disease (ICD-9) codes. A large heterogenous population, comprising up to 40 percent of annual discharges from the Hematology/Oncology service, was identified. If management decided to add an acute-care, palliative medicine unit to the hospital, these are the patients who would benefit. The study predicted a significant change in patient profile, acuity, complexity, and resource utilization in current palliative care services. This study technique predicted the actual clinical load of the acute-care unit when it opened and was very helpful in program development. Our model predicted that 695 patients would be admitted to the acute-care palliative medicine unit in the first year of operation; 655 patients were actually admitted during this time.
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Affiliation(s)
- Declan Walsh
- The Harry R. Horvitz Center for Palliative Medicine (A World Health Organization Demonstration Project), Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Michael N, O'Callaghan C, Brooker JE, Walker H, Hiscock R, Phillips D. Introducing a model incorporating early integration of specialist palliative care: A qualitative research study of staff's perspectives. Palliat Med 2016. [PMID: 26224103 DOI: 10.1177/0269216315598069] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [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 has evolved to encompass early integration, with evaluation of patient and organisational outcomes. However, little is known of staff's experiences and adaptations when change occurs within palliative care services. AIM To explore staff experiences of a transition from a service predominantly focused on end-of-life care to a specialist service encompassing early integration. DESIGN Qualitative research incorporating interviews, focus groups and anonymous semi-structured questionnaires. Data were analysed using a comparative approach. Service activity data were also aggregated. SETTING/PARTICIPANTS A total of 32 medical, nursing, allied health and administrative staff serving a 22-bed palliative care unit and community palliative service, within a large health service. RESULTS Patients cared for within the new model were significantly more likely to be discharged home (7.9% increase, p = 0.003) and less likely to die in the inpatient unit (10.4% decrease, p < 0.001). While early symptom management was considered valuable, nurses particularly found additional skill expectations challenging, and perceived patients' acute care needs as detracting from emotional and end-of-life care demands. Staff views varied on whether they regarded the new model's faster-paced work-life as consistent with fundamental palliative care principles. Less certainty about care goals, needing to prioritise care tasks, reduced shared support rituals and other losses could intensify stress, leading staff to develop personalised coping strategies. CONCLUSION Services introducing and researching innovative models of palliative care need to ensure adequate preparation, maintenance of holistic care principles in faster work-paced contexts and assist staff dealing with demands associated with caring for patients at different stages of illness trajectories.
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Affiliation(s)
- Natasha Michael
- Palliative Care Service, Cabrini Health Australia, Prahran, VIC, Australia Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic, Australia
| | - Clare O'Callaghan
- Palliative Care Service, Cabrini Health Australia, Prahran, VIC, Australia Department of Medicine, St Vincent's University Hospital, The University of Melbourne, Parkville, Vic, Australia
| | - Joanne E Brooker
- Cabrini Monash Psycho-oncology, Cabrini Health Australia, Prahran, VIC, Australia Department of Psychiatry, Monash University, Melbourne, VIC, Australia
| | - Helen Walker
- Palliative Care Service, Cabrini Health Australia, Prahran, VIC, Australia
| | - Richard Hiscock
- Mercy Hospital for Women, Melbourne, VIC, Australia Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville VIC, Australia
| | - David Phillips
- David Phillips, Business Intelligence Unit, Cabrini Health Australia, Prahran, VIC, Australia
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Whitford K, Shah ND, Moriarty J, Branda M, Thorsteinsdottir B. Impact of a palliative care consult service. Am J Hosp Palliat Care 2013; 31:175-82. [PMID: 23552659 DOI: 10.1177/1049909113482746] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Established hospital palliative care consult services (PCCS) have been associated with reduced costs and length of stay, decreased symptom burden, and increased satisfaction with care. Using a retrospective case-control design, we analyzed administrative data of patients seen by PCCS while hospitalized at the Rochester, Minnesota Mayo Clinic hospitals from 2003 to 2008. The PCCS patients were matched to 3:1. A total of 1477 patients seen by the PCCS were matched with 4431 patients not seen. Costs for patients seen and discharged alive were US $35,449 (95% confidence interval [CI] US $34,157-US $36,686) compared to US $37,447 (95% CI US $36,734-US $38,126), without PCCS consultation. Costs for PCCS patients that died during hospitalization were US $54,940 (95% CI US $51,483-US $58,576) and non-PCCS patients were US $79,660 (95% CI US $76,614-US $83,398).
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Barbosa LA, Fernandes PL, Muniz PC, Prates D. Clinical pathology differences in laboratory utilization in hospice and nonhospice units. Am J Hosp Palliat Care 2009; 26:79-83. [PMID: 19349456 DOI: 10.1177/1049909109332092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A significant difference can be observed between hospice and nonhospice philosophy. Nonhospice units direct its effort to cure and sustain patient's life using disease-modifying therapeutic procedures, while hospice units focus on patient's quality of life. However, despite the differences between the 2 basic philosophies in question, both approaches share 1 aspect in common: the correct diagnosis of the patient. In any case above, laboratory analysis is a valuable tool. This work aims to compare the laboratory utilization between nonhospice cancer and hospice cancer units. Laboratory requests from patients within a 1-year period were evaluated and the hospice laboratory profile was presented. We demonstrated that nonhospice unit had a major volume of requested laboratory test than hospice unit, but for inpatients this difference was not so dramatic.
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Affiliation(s)
- Leandro A Barbosa
- INCa-Instituto Nacional de Câncer, Hospital do Câncer IV, Unidade de Cuidados Paliativos, Divisão Técnico Científica, Vila Isabel, Rio de Janeiro, Brazil.
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Lagman R, Walsh D, Heintz J, Legrand SB, Davis MP. A day in the life: a case series of acute care palliative medicine--the Cleveland model. Am J Hosp Palliat Care 2008; 25:24-32. [PMID: 18292480 DOI: 10.1177/1049909107307375] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Palliative care in advanced disease is complex. Knowledge and experience of symptom control and management of multiple complications are essential. An interdisciplinary team is also required to meet the medical and psychosocial needs in life-limiting illness. Acute care palliative medicine is a new concept in the spectrum of palliative care services. Acute care palliative medicine, integrated into a tertiary academic medical center, provides expert medical management and specialized care as part of the spectrum of acute medical care services to this challenging patient population. The authors describe a case series to provide a snapshot of a typical day in an acute care inpatient palliative medicine unit. The cases illustrate the sophisticated medical care involved for each individual and the important skill sets of the palliative medicine specialist required to provide high-quality acute medical care for the very ill.
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Affiliation(s)
- Ruth Lagman
- Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic Taussig Cancer Center, Cleveland, Ohio
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Abstract
PURPOSE The purpose of this analysis is to trace the evolution of the concept of palliative in the United States, explicate its meanings, and draw comparisons with other related concepts such as hospice care and terminal care. METHODS Rodgers' evolutionary method was used as an organizing framework for the concept analysis. Data were collected from a review of CINAHL, MEDLINE, CANCERLIT, PsycINFO and Sociological Abstracts databases using 'palliative care' and 'United States' as keywords. Articles written in the English language, with an abstract, published between 1965 and 2003 were considered. Data were synthesized to identify attributes, antecedents and consequences of palliative care. FINDINGS There has been a significant evolution in understanding of the palliative care concept in the United States over the last few decades, which has resulted in the emergence of new models of palliative care. Four attributes of the current palliative care concept were identified: (1) total, active and individualized patient care, (2) support for the family, (3) interdisciplinary teamwork and (4) effective communication. Results reinforce that cure and palliation are not mutually exclusive categories. CONCLUSIONS The scope of palliative care has evolved to include a wide range of patient populations who may not be appropriately termed 'dying' but for whom alleviation of suffering and improvement of quality of life may be very relevant goals. The ultimate success of the new models of palliative care will eventually rest upon the commitment of health professionals to recognize and integrate the changing concept of palliative care into everyday practice.
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Affiliation(s)
- Salimah H Meghani
- School of Nursing and Biomedical Ethics, University of Pennsylvania, Philadelphia 19104, USA.
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Tibi-Lévy Y, d'Hérouville D. Developing an operational typology of patients hospitalised in palliative care units. Palliat Med 2004; 18:248-58. [PMID: 15198138 DOI: 10.1191/0269216304pm871oa] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The objective of this study was to develop an operational typology of patients hospitalised in palliative care units (PC units) and to characterize these populations. Prospective data were collected in four PC units over three-week periods, generating a sample of 139 cases. Five classes of patient were identified and described via a factorial analysis and a classification: metastatic cancers requiring significant psychological attention, terminally ill patients, ENT cancers, neurological diseases and elderly patients. A more detailed study revealed differences between metastatic cancers, younger patients, very dependent patients and the other patients. We present the sociodemographic, clinical and cost per patient profiles of each class of patient. Having access to a broader sample of PC units and of patients would allow for a more complete typology.
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Affiliation(s)
- Yaël Tibi-Lévy
- Centre de Recherche en Economie et Gestion Appliquée à la Santé, INSERM U537/CNRS UMR 8052, Paris, France.
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Stuart B, D'Onofrio CN, Boatman S, Feigelman G. CHOICES: Promoting Early Access to End-of-Life Care Through Home-Based Transition Management. J Palliat Med 2003; 6:671-83. [PMID: 14516514 DOI: 10.1089/109662103768253849] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
CHOICES is a comprehensive home-based care coordination program designed to bridge the gap between home health and hospice for Medicare + Choice enrollees with advanced chronic illness in San Francisco's East Bay region. Key elements of the program include physician education, enrollment of patients with high disease burden who may not be terminally ill, co-management of care with the primary physician, and an advanced practice clinical team that provides comprehensive in-home assessments, a flexible mix of life-prolonging and palliative care that evolves with disease progression, focused education and advance planning, and caregiver support. During a 42-month demonstration, 208 patients were enrolled in the program. Eighty percent had a non-cancer diagnosis; 40% were people of color. After an 8-month follow-up, 44% of the study cohort had died in the program or after transfer to hospice, 51% had been discharged, and 5% remained active. Median length of stay for decedents was 260 days. Preliminary evidence supports the program's feasibility and acceptability to patients, families, physicians, and agency partners. However, the uncertain future of Medicare + Choice and of managed care may jeopardize the program's sustainability. Policymakers and taxpayers will need to determine how to care for the growing number of chronically ill elderly who wish to remain at home as illness advances. The care needs of these patients and their families may overwhelm a health system organized around hospital treatment of acute illness.
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Affiliation(s)
- Brad Stuart
- Sutter Visiting Nurse Association and Hospice, 1900 Powell Street, Suite 300, Emeryville, CA 94608, USA.
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Davis MP. In response to Development and Implementation of an Inpatient Acute Palliative Care Service. J Palliat Med 2002; 5:645; author reply 646-7. [PMID: 12243690 DOI: 10.1089/109662102760269931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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