Economics of Palliative Care for Cancer: Interpreting Current Evidence, Mapping Future Priorities for Research

Cost of Hospitalization Associated with Inpatient Goals-of-Care Program Implementation at a Comprehensive Cancer Center: A Propensity Score Analysis

The impact of goals-of-care programs on acute hospitalization costs is unclear. We compared the hospitalization cost in an 8-month period before implementation of a multimodal interdisciplinary goals-of-care program (1 May 2019 to 31 December 2019) to an 8-month period after program implementation (1 May 2020 to 31 December 2020). Propensity score weighting was used to adjust for differences in potential covariates. The primary outcome was total direct cost during the hospital stay for each index hospitalization. This analysis included 6977 patients in 2019 and 5964 patients in 2020. The total direct cost decreased by 3% in 2020 but was not statistically significant (ratio 0.97, 95% CI 0.92, 1.03). Under individual categories, there was a significant decrease in medical oncology (ratio 0.58, 95% CI 0.50, 0.68) and pharmacy costs (ratio 0.86, 95% CI 0.79, 0.96), and an increase in room and board (ratio 1.06, 95% CI 1.01, 1.10). In subgroup analysis, ICU patients had a significant reduction in total direct cost after program implementation (ratio 0.83, 95% CI 0.72, 0.94). After accounting for the length of ICU admission, we found that the total direct cost per hospital day was no longer different between 2019 and 2020 (ratio 0.986, 95% CI 0.92, 1.05), suggesting that shorter ICU admissions likely explained much of the observed cost savings. This study provides real-world data on how "in-the-moment" GOC conversations may contribute to reduced hospitalization costs among ICU patients.

Methodological challenges and potential solutions for economic evaluations of palliative and end-of-life care: A systematic review

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.

Palliative care needs and barriers in an urban Ugandan Emergency Department: A mixed-methods survey of emergency healthcare workers and patients

Background

Palliative Care offers patient-centered, symptom-focused relief for patients with incurable disease, and early integration of palliative care ensures quality of life and death while reducing medical impoverishment. The Emergency Department is an ideal yet understudied, under-utilized location to initiate palliative care.

Objective

To evaluate the palliative care needs of patients with incurable disease and perceived barriers amongst healthcare providers in the Emergency Department of Kiruddu National Referral Hospital, Kampala, Uganda.

Methods

A mixed methods survey of Emergency Department healthcare workers and patients was conducted. A crosse sectional survey of ninety-nine patients was conducted using the integrated Palliative Care Outcome Scale (IPOS). Eleven interviews were conducted with healthcare workers at Kiruddu Hospital, identified by purposive sampling. Descriptive and inferential statistics were used to analyze quantitative data.. Grounded theory approach was used to construct the in depth interview questions, code and analyze qualitative results and collapse these results into final themes.

Results

The most common diagnoses were HIV/HIV-TB (32 %), heart disease (18 %), and sickle cell disease (14 %). The prevalence of unmet palliative care needs was substantial: more that 70 % of patients reported untreated symptoms e.g., pain, fatigue, difficulty breathing. Seventy-seven percent of the population reported severe or overwhelming pain. The main barriers to provision of palliative care in the Emergency Department as identified by healthcare workers were: (1) lack of adequate training in palliative care; (2) Challenges due to patient volume and understaffing; (3) the misconception that palliative care is associated with pain management alone; (4) Financial constraints as the greatest challenge faced by patients with incurable disease.

Conclusions

We report a high prevalence of unmet palliative care needs among patients in this urban Ugandan Emergency Department, and important barriers reported by emergency healthcare providers. Identification of these barriers offers opportunities to overcome them including harnessing novel mHealth interventions such as clinical support apps or telehealth palliative care consultants. Integration of palliative care in this setting would improve the care of vulnerable patients, provide healthcare workers with an additional care modality while likely adding value to the health system.

End-of life medical spending and care pathways in the last 12 months of life: A comprehensive analysis of the national claims database in France

BACKGROUND

To inform policy makers on efficient provision of end-of-life care, we estimated the 12-month medical expenditures of French decedents in 2015.

METHODS

We estimated total medical expenditures by service type and diagnosis category, and analyzed care pathways for breast cancer, dementia, chronic obstructive lung disease.

RESULTS

501,121 individuals died in 2015, 59% of whom were in a hospital at the time of death. The aggregated spending totaled 9% of total health expenditures, a mean of €28,085 per capita, 44% of which was spent during the last 3 months of life. Hospital admissions represented over 70% of total expenditures; 21.3% of the population used hospital palliative care services in their last year of life. Analyses performed on breast cancer, dementia and lung disease found that differences in care pathways markedly influenced spending and were not simply explained by patients characteristics.

CONCLUSION

Diagnoses and care trajectories, including repeated hospital stays, are the main drivers of the last year of life expenditures. Our data suggests that early identification of patients requiring palliative care and community-based end-of-life service delivery is feasible and could better support patients, families and caregivers with constant or reduced costs.

'When a patient chooses to die at home, that's what they want… comfort, home': Brilliance in community-based palliative care nursing

INTRODUCTION

To redress the scholarly preoccupation with gaps, issues, and problems in palliative care, this article extends previous findings on what constitutes brilliant palliative care to ask what brilliant nursing practices are supported and promoted.

METHODS

This study involved the methodology of POSH-VRE, which combines positive organisational scholarship in healthcare (POSH) with video-reflexive ethnography (VRE). From August 2015 to May 2017, inclusive, nurses affiliated with a community health service who delivered palliative care, contributed to this study as co-researchers (n = 4) or participants (n = 20). Patients who received palliative care (n = 30) and carers (n = 16) contributed as secondary participants, as they were part of observed instances of palliative care. With a particular focus on the practices and experiences that exceeded expectations and brought joy and delight, the study involved capturing video-recordings of community-based palliative care in situ; reflexively analysing the recordings with the nurses; as well as ethnography to witness, experience, and understand practices and experiences. Data were analysed, teleologically, to clarify what brilliant practices were supported and promoted.

RESULTS

Brilliant community-based palliative care nursing largely involved maintaining normality in patients' and carers' lives. The nurses demonstrated this by masking the clinical aspects of their role, normalising these aspects, and appreciating alternative 'normals'.

CONCLUSION

Redressing the scholarly preoccupation with gaps, issues, and problems in palliative care, this article demonstrates how what is ordinary is extraordinary. Specifically, given the intrusiveness and abnormalising effects of technical clinical interventions, brilliant community-based palliative care can be realised when nurses enact practices that serve to promote a patient or carer to normality.

PATIENT OR PUBLIC CONTRIBUTION

Patients and carers contributed to this study as participants, while nurses contributed to this study as co-researchers in the conduct of the study, the analysis and interpretation of the data, and the preparation of the article.

Early palliative care consultation offsets hospitalization duration and costs for elderly patients with traumatic brain injuries: Insights from a Level 1 trauma center

We identified factors and outcomes associated with inpatient palliative care (PC) consultation, stratified into early and late timing, for patients over age 65 with traumatic brain injuries (TBI). Patients over age 65 presenting to a single institution with TBI and intracranial hemorrhage from January 2013-September 2020 were included. Patient demographics and various outcomes were analyzed. Inpatient PC consultation was uncommon (4 % out of 576 patients). Characteristics associated with likelihood of consultation were severe TBI (OR = 5.030, 95 % CI 1.096-23.082, p =.038) and pre-existing dementia (OR = 6.577, 95 % CI 1.726-25.073, p =.006). Average consultation timing was 8.6 (standard deviation ± 7.0) days. Patients with PC consults had longer overall (p =.0031) and intensive care unit (ICU) length of stays (LOS) (p <.0001), more days intubated (p <.0001) and higher costs (p =.0006), although those with earlier-than-average PC consultation had shorter overall (p =.0062) and ICU (p =.011) LOS as well as fewer ventilator days (p =.030) and lower costs (p =.0003). Older patients with TBI are more likely to receive PC based on pre-existing dementia and severe TBI. Patients with PC consultations had worse LOS and higher costs. However, these effects were mitigated by earlier PC involvement. Our study emphasizes the need for timely PC consultation in a vulnerable patient population.

Personalizing the Setting of Palliative Care Delivery for Patients with Advanced Cancer: "Care Anywhere, Anytime"

OPINION STATEMENT

The specialty of palliative care has evolved over time to provide symptom management, psychosocial support, and care planning for patients with cancer throughout the disease continuum and in multiple care settings. This review examines the delivery and impact of palliative care in the outpatient, inpatient, and community-based settings. The article will discuss how these 3 palliative care settings can work together to optimize patient outcomes under a unifying model of palliative care "anywhere, anytime" and how to prioritize palliative care services when resources are limited. Many patients with advanced cancer receive care from each of the 3 branches of palliative care-outpatient, inpatient, and community-based settings-at some point along their disease trajectory. Early on, outpatient clinics provide longitudinal supportive care concurrent with active disease-modifying treatments. Telemedicine appointments can serve patients remotely to minimize their need to travel. When patients experience functional decline, community-based palliative care services can provide support and monitoring for patients at home. When patients develop acute symptomatic complications requiring admission, inpatient care consultation teams are essential for symptom management and goals-of-care discussions. For patients in severe distress, receiving care in a palliative care unit that provides intensive symptom control and facilitates complex discharge planning is ideal. Under a unifying model of palliative care designed to offer care "anywhere, anytime," the 3 branches of palliative care could work in unison to support each other, minimize gaps in care, and optimize patient outcomes.

Mapping service standards and guidelines to support accreditation processes &#x2013; a case study of a collaborative effort worth replicating

Health services respond to myriad practice standards and guidelines that regulate, monitor, and improve the safety and quality of healthcare. Although important, information overload and compliance fatigue for accreditation can be burdensome for service managers and clinicians. To address this, and ultimately improve the safety and quality of care, this case study demonstrates how a mapping exercise was completed to synthesise seven practice standards and guidelines relevant to palliative care; and develop an online resource to aid accreditation efforts and improve palliative care. A working group, comprised of service managers, clinicians, and academics, mapped a state-wide blueprint to improve palliative care against seven unique practice standards and guidelines, most of which were national in scope. This project culminated with a freely available online resource to translate the standards and guidelines for accreditation - a resource that supports service managers and clinicians across public and private health sectors to readily determine whether and how they demonstrated safety and quality in the context of palliative care and pursue accreditation. By developing one matrix, there is opportunity to alleviate information overload and compliance fatigue for service managers and clinicians. Despite its focus on palliative care, this case study demonstrates how to collaboratively map distinct practice standards and guidelines and form a resource to aid accreditation efforts to improve healthcare.

Trends and outcomes of early and late palliative care consultation for adult patients with glioblastoma: A SEER-Medicare retrospective study

Background

Glioblastoma (GBM) carries a poor prognosis despite standard of care. Early palliative care (PC) has been shown to enhance survival and quality of life while reducing healthcare costs for other cancers. This study investigates differences in PC timing on outcomes for patients with GBM.

Methods

This study used Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 1997 to 2016. Based on ICD codes, three groups were defined: (1) early PC within 10 weeks of diagnosis, (2) late PC, and (3) no PC. Outcomes were compared between the three groups.

Results

Out of 10 812 patients with GBM, 1648 (15.24%) patients had PC consultation with an overall positive trend over time. There were no significant differences in patient characteristics. The late PC group had significantly higher number of hospice claims (1.06 ± 0.69) compared to those without PC, in the last month of life. There were significant differences in survival among the three groups (P < .0001), with late PC patients with the longest mean time to death from diagnosis (11.72 ± 13.20 months).

Conclusion

We present the first investigation of PC consultation prevalence and outcomes, stratified by early versus late timing, for adult GBM patients. Despite an overall increase in PC consultations, only a minority of GBM patients receive PC. Patients with late PC had the longest survival times and had greater hospice use in the last month of life compared to other subgroups. Prospective studies can provide additional valuable information about this unique population of patients with GBM.

Palliative Care in Colorectal Cancer

Approximately 25% of patients present with liver metastases at the time of the first diagnosis and up to 50% will further develop recurrence in the liver during their disease course. Traditionally approached surgically, by resection of the primitive tumor or stoma, the management to incurable stage IV colorectal cancer patients has significantly changed over the last three decades and is nowadays multidisciplinary, with a pivotal role played by chemotherapy. Most patients with stage IV colorectal cancer have a poor prognosis, but numerous palliative modalities are available today. When a cure is no longer possible, treatment is directed toward providing symptomatic relief. Good symptom management in oncology is associated with improved patient and family quality of life, greater treatment compliance, and may even offer survival advantages.

Early palliative care associated with lower costs for adults with advanced cancer: evidence from Hungary

OBJECTIVE

Palliative Care Consult Service (PCCS) programme was established in Hungary to provide palliative care to hospitalised patients with complex needs and to coordinate integrated care across providers. The aim of this study was to measure the association of PCCS with healthcare costs from payer's perspective.

METHODS

Study population consisted of patients with metastatic cancer, who were admitted to the Clinical Centre of the University of Pécs between 2014 and 2016. Patients who did not die within 180 days from enrolment were excluded. Patients receiving services from PCCS team (intervention patients) were compared to patients receiving usual care (controls). The two populations were matched using propensity scores. Data were obtained from electronic medical records linked to claims data.

RESULTS

For patients who were involved in PCCS at least 60 days before their death, the costs of care outside the acute hospital were higher. However, this was offset by savings in hospital costs so that the total healthcare cost was significantly reduced (p = 0.034). The proportion of patients who died in the hospital was lower in the PCCS group compared to the usual care group (66% vs. 85%, p = 0.022).

CONCLUSION

Timely initiation of palliative care for hospitalised patients is associated with cost savings for the healthcare system.

Factors Associated with the Costs of Palliative Care: A Retrospective Cost Analysis at a University Cancer Hospital in Brazil

Background: There have been few studies evaluating the costs of palliative care (PC) in low- and middle-income countries (LMICs), especially for patients with cancer. Objectives: The objective of this study was to identify the sociodemographic and clinical variables that could explain the cost per day of PC for cancer in Brazil. Methods: This was a retrospective cost analysis of PC at a quaternary cancer center in São Paulo, Brazil, between January 2010 and December 2013. Factors influencing the cost per day were assessed with generalized linear models and generalized linear-mixed models in which the random effect was the site of the cancer. Results: The study included 2985 patients. The mean total cost per patient was $12,335 (standard deviation [SD] = 14,602; 95% confidence interval [CI] = 11,803 to 12,851). The mean cost per day per patient was $325.50 (SD = 246.30, 95% CI = 316.60 to 334.30). There were statistically significant differences among cancer sites in terms of the mean cost per day. Multivariate analysis revealed that the drivers of cost per day were Karnofsky performance status, the number of hospital admissions, referral to PC, and place of death. Place of death had the greatest impact on the cost per day; death in a hospital and in hospice care increased the mean cost per day by $1.56 and $1.83, respectively. Conclusion: To allocate resources effectively, PC centers in LMICs should emphasize early enrollment of patients at PC outpatient clinics, to avoid hospital readmission, as well as advance planning of the place of death.

Cost Savings Associated With Palliative Care Among Older Adults With Advanced Cancer

BACKGROUND

There is inconsistent evidence that palliative care intervention decreases total healthcare expenditure at end-of-life for oncology patients. This inconsistent evidence may result from small sample sizes at single institution studies and disparate characterization of costs across studies. Comprehensive studies in population-based datasets are needed to fully understand the impact of palliative care on total healthcare costs. This study analyzed the impact of palliative care on total healthcare costs in a nationally representative sample of advanced cancer patients.

METHODS

We conducted a matched cohort study among Medicare patients with metastatic lung, colorectal, breast and prostate cancers. We matched patients who received a palliative care consultation to similar patients who did not receive a palliative care consultation on factors related to both the receipt of palliative care and end of life costs. We compared direct costs between matched patients to determine the per-patient economic impact of a palliative care consultation.

RESULTS

Patients who received a palliative care consultation experienced an average per patient cost of $5,834 compared to $7,784 for usual care patients (25% decrease; p < 0.0001). Palliative care consultation within 7 days of death decreased healthcare costs by $451, while palliative care consultation more than 4 weeks from death decreased costs by $4,643.

CONCLUSION

This study demonstrates that palliative care has the capacity to substantially reduce healthcare expenditure among advanced cancer patients. Earlier palliative care consultation results in greater cost reductions than consultation in the last week of life.

Expert Consensus for Treating Cancer Patients During the Pandemic of SARS-CoV-2

The sudden pandemic of SARS-Cov-2 (also known as novel coronavirus disease 2019, COVID-19) poses a severe threat to hundreds of millions of lives in the world. The complete cure of the virus largely relies on the immune system, which becomes particularly a challenge for the cancer subjects, whose immunity is generally compromised. However, in a constant evolving situation, the clinical data on the prevalence of SARS-Cov-2 for cancer patients is still limited. On top of a wide range of medical references and interim guidelines including CDC, NCI, ASCO, ESMO, NCCN, AACR, ESMO, and the National Health Commission of China, etc., we formed into a guideline based on our experience in our specialized cancer hospital in Wuhan, the originally endemic center of the virus. Furthermore, we formulated an expert consensus which was developed by all contributors from different disciplines after fully discussion based on our understanding and analysis of limited information of COVID-19. The consensus highlighted a multidisciplinary team diagnostic model with assessment of the balance between risks and benefits prior to treatment, individualizing satisfaction of patients' medical needs, and acceptability in ethics and patients' socio-economic conditions.

USP4 function and multifaceted roles in cancer: a possible and potential therapeutic target

Cancer remains one of the major culprits causing disease-related deaths and leads to a high morbidity and similar mortality. Insidious onset, difficult early detection and a lack of broad-spectrum and effective multi-cancer therapeutic targets have limited the prolongation of cancer patients’ survival for decades. Therefore, a versatile therapeutic target which is involved in various cancer-related signaling pathways and different cancers may be more effective for cancer targeted therapy. USP4, one of the DUBs members which participates in deubiquitination, an inverse process of ubiquitination, can regulate various classical cancer-related signaling pathways, and thereby plays a vital role in some pathological and physiological processes including tumor initiation and progression. Recently, USP4 has been found to exert versatile influences on cells proliferation, migration and invasion, also apoptosis of various tumors. Moreover, USP4 can also act as a prognostic biomarker in several cancers. This review will give a comprehensive introduction of USP4 about its regulatory mechanisms, related signaling pathways, pathophysiological functions and the roles in various cancers which may help us better understand its biological functions and improve future studies to construct suitable USP4-targeted cancer therapy system.