Community-based specialist palliative care teams and health system costs at end of life: a retrospective matched cohort study

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Abstract

<div class="section"> <a class="named-anchor" id="d3487155e102">  </a> <h5 class="section-title" id="d3487155e103">Background:</h5> <p id="d3487155e105">Access to community-based specialist palliative care teams has been shown to improve patients’ quality of life; however, the impact on health system expenditures is unclear. This study aimed to determine whether exposure to these teams reduces health system costs compared with usual care. </p> </div><div class="section"> <a class="named-anchor" id="d3487155e107">  </a> <h5 class="section-title" id="d3487155e108">Methods:</h5> <p id="d3487155e110">We conducted a retrospective matched cohort study in Ontario, Canada, using linked administrative data. Decedents treated by 1 of 11 community-based specialist palliative care teams in 2009/10 and 2010/11 (the exposed group) were propensity score matched (comorbidity, extent of home care, etc.) 1 to 1 to similar decedents in usual care (the unexposed group). The teams are comprised of a core group of specialized physicians, nurses and other providers; their role is to manage symptoms around the clock, provide education and coordinate care. Our primary outcome was the overall difference in health system costs (among 5 health care sectors) between all matched pairs of exposed versus unexposed patients in the last 30 days of life. </p> </div><div class="section"> <a class="named-anchor" id="d3487155e112">  </a> <h5 class="section-title" id="d3487155e113">Results:</h5> <p id="d3487155e115">The total cohort of decedents included 3109 matched pairs. Among matched pairs, the mean health system cost difference was $512 (95% confidence interval [CI] −$641 to −$383) lower in the last 30 days among exposed than among unexposed patients. In the last 30 days, the mean home care costs of the exposed group were $189 higher (95% CI −$151 to $227) than those of the unexposed group, but their mean hospital costs were $733 lower (95% CI −$950 to −$516). </p> </div><div class="section"> <a class="named-anchor" id="d3487155e117">  </a> <h5 class="section-title" id="d3487155e118">Interpretation:</h5> <p id="d3487155e120">Our study suggests that health system costs are lower for patients who have access to community-based specialist teams than for those who receive usual care alone, largely because of decreased hospital costs. Ensuring access to in-home palliative care support, as provided by these teams, is an efficacious strategy for reducing health care expenditures at the end of life. </p> </div>

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Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers

Bárbara Gomes, Natalia Calanzani, Vito Curiale … (2013)

Background Extensive evidence shows that well over 50% of people prefer to be cared for and to die at home provided circumstances allow choice. Despite best efforts and policies, one-third or less of all deaths take place at home in many countries of the world. Objectives 1. To quantify the effect of home palliative care services for adult patients with advanced illness and their family caregivers on patients' odds of dying at home; 2. to examine the clinical effectiveness of home palliative care services on other outcomes for patients and their caregivers such as symptom control, quality of life, caregiver distress and satisfaction with care; 3. to compare the resource use and costs associated with these services; 4. to critically appraise and summarise the current evidence on cost-effectiveness. Search methods We searched 12 electronic databases up to November 2012. We checked the reference lists of all included studies, 49 relevant systematic reviews, four key textbooks and recent conference abstracts. We contacted 17 experts and researchers for unpublished data. Selection criteria We included randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITSs) evaluating the impact of home palliative care services on outcomes for adults with advanced illness or their family caregivers, or both. Data collection and analysis One review author assessed the identified titles and abstracts. Two independent reviewers performed assessment of all potentially relevant studies, data extraction and assessment of methodological quality. We carried out meta-analysis where appropriate and calculated numbers needed to treat to benefit (NNTBs) for the primary outcome (death at home). Main results We identified 23 studies (16 RCTs, 6 of high quality), including 37,561 participants and 4042 family caregivers, largely with advanced cancer but also congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), HIV/AIDS and multiple sclerosis (MS), among other conditions. Meta-analysis showed increased odds of dying at home (odds ratio (OR) 2.21, 95% CI 1.31 to 3.71; Z = 2.98, P value = 0.003; Chi2 = 20.57, degrees of freedom (df) = 6, P value = 0.002; I2 = 71%; NNTB 5, 95% CI 3 to 14 (seven trials with 1222 participants, three of high quality)). In addition, narrative synthesis showed evidence of small but statistically significant beneficial effects of home palliative care services compared to usual care on reducing symptom burden for patients (three trials, two of high quality, and one CBA with 2107 participants) and of no effect on caregiver grief (three RCTs, two of high quality, and one CBA with 2113 caregivers). Evidence on cost-effectiveness (six studies) is inconclusive. Authors' conclusions The results provide clear and reliable evidence that home palliative care increases the chance of dying at home and reduces symptom burden in particular for patients with cancer, without impacting on caregiver grief. This justifies providing home palliative care for patients who wish to die at home. More work is needed to study cost-effectiveness especially for people with non-malignant conditions, assessing place of death and appropriate outcomes that are sensitive to change and valid in these populations, and to compare different models of home palliative care, in powered studies. PLAIN LANGUAGE SUMMARY Effectiveness and cost-effectiveness of home-based palliative care services for adults with advanced illness and their caregivers When faced with the prospect of dying with an advanced illness, the majority of people prefer to die at home, yet in many countries around the world they are most likely to die in hospital. We reviewed all known studies that evaluated home palliative care services, i.e. experienced home care teams of health professionals specialised in the control of a wide range of problems associated with advanced illness – physical, psychological, social, spiritual. We wanted to see how much of a difference these services make to people's chances of dying at home, but also to other important aspects for patients towards the end of life, such as symptoms (e.g. pain) and family distress. We also compared the impact on the costs with care. On the basis of 23 studies including 37,561 patients and 4042 family caregivers, we found that when someone with an advanced illness gets home palliative care, their chances of dying at home more than double. Home palliative care services also help reduce the symptom burden people may experience as a result of advanced illness, without increasing grief for family caregivers after the patient dies. In these circumstances, patients who wish to die at home should be offered home palliative care. There is still scope to improve home palliative care services and increase the benefits for patients and families without raising costs.

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Evidence on the cost and cost-effectiveness of palliative care: a literature review.

Sinead O'Hara, Leslie A Brick, Samantha Smith … (2014)

In the context of limited resources, evidence on costs and cost-effectiveness of alternative methods of delivering health-care services is increasingly important to facilitate appropriate resource allocation. Palliative care services have been expanding worldwide with the aim of improving the experience of patients with terminal illness at the end of life through better symptom control, coordination of care and improved communication between professionals and the patient and family. To present results from a comprehensive literature review of available international evidence on the costs and cost-effectiveness of palliative care interventions in any setting (e.g. hospital-based, home-based and hospice care) over the period 2002-2011. Key bibliographic and review databases were searched. Quality of retrieved papers was assessed against a set of 31 indicators developed for this review. PubMed, EURONHEED, the Applied Social Sciences Index and the Cochrane library of databases. A total of 46 papers met the criteria for inclusion in the review, examining the cost and/or utilisation implications of a palliative care intervention with some form of comparator. The main focus of these studies was on direct costs with little focus on informal care or out-of-pocket costs. The overall quality of the studies is mixed, although a number of cohort studies do undertake multivariate regression analysis. Despite wide variation in study type, characteristic and study quality, there are consistent patterns in the results. Palliative care is most frequently found to be less costly relative to comparator groups, and in most cases, the difference in cost is statistically significant.

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Using the Johns Hopkins Aggregated Diagnosis Groups (ADGs) to predict mortality in a general adult population cohort in Ontario, Canada.

Walter P Wodchis, David Anderson, Carl van Walraven … (2011)

Administrative healthcare databases are increasingly used for health services and comparative effectiveness research. When comparing outcomes between different treatments, interventions, or exposures, the ability to adjust for differences in the risk of the outcome occurring between treatment groups is important. Similarly, when conducting healthcare provider profiling, adequate risk-adjustment is necessary for conclusions about provider performance to be valid. There are limited validated methods for risk adjustment in ambulatory populations using administrative healthcare databases. To examine the ability of the Johns Hopkins' Aggregated Diagnosis Groups (ADGs) to predict mortality in a general ambulatory population cohort. Retrospective cohort constructed using population-based administrative data. All 10,498,413 residents of Ontario, Canada between the ages of 20 and 100 years who were alive on their birthday in 2007. Subjects were randomly divided into derivation and validation samples. Death within 1 year of the subject's birthday in 2007. A logistic regression model consisting of age, sex, and indicator variables for 28 of the 32 ADG categories had excellent discrimination: the c-statistic (equivalent to the area under the receiver operating characteristic curve) was 0.917 in both derivation and validation samples. Furthermore, the model showed very good calibration. In comparison, the use of the Charlson comorbidity index or the Elixhauser comorbidities resulted in a minor decrease in discrimination compared with the use of the ADGs. Logistic regression models using age, sex, and the John Hopkins ADGs were able to accurately predict 1-year mortality in a general ambulatory population of subjects.

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Journal

Title: CMAJ Open

Abbreviated Title: cmajo

Publisher: Joule Inc.

ISSN (Electronic): 2291-0026

Publication date Created: February 11 2019

Publication date Created: 2019

Publication date (Electronic): February 11 2019

Publication date (Print): 2019

Volume: 7

Issue: 1

Pages: E73-E80

Article

DOI: 10.9778/cmajo.20180113

PMC ID: 6375224

PubMed ID: 30755414

SO-VID: 1ad9d072-0055-421a-a9c8-6697adb46a62

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Community-based specialist palliative care teams and health system costs at end of life: a retrospective matched cohort study

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Most cited references 18

Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers

Evidence on the cost and cost-effectiveness of palliative care: a literature review.

Using the Johns Hopkins Aggregated Diagnosis Groups (ADGs) to predict mortality in a general adult population cohort in Ontario, Canada.

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