A cost-consequence analysis of normalised advance care planning practices among people with chronic diseases in hospital and community settings

Peter Cleasby,Tomiko Barrett,Sarah Jeong,Simon Deeming,Se Ok Ohr,Ryan Davey

doi:10.1186/s12913-021-06749-x

Abstract

BackgroundA growing body of international literature concurs that comprehensive and complex Advance Care Planning (ACP) programs involving specially qualified or trained healthcare professionals are effective in increasing documentation of Advance Care Directives (ACDs), improving compliance with patients’ wishes and satisfaction with care, and quality of care for patients and their families. Economic analyses of ACDs and ACP have been more sporadic and inconclusive. This study aimed to contribute to the evidence on resource use associated with implementation of ACP and to inform key decision-makers of the resource implications through the conduct of a cost-consequence analysis of the Normalised Advance Care Planning (NACP) trial.MethodsThe outcomes for the economic evaluation included the number of completed “legally binding” ACDs and the number of completed Conversation Cards (CC). The cost analysis assessed the incremental difference in resource utilisation between Usual Practice and the Intervention. Costs have been categorised into: 1) Contract staff costs; 2) Costs associated with the development of the intervention; 3) Implementation costs; 4) Intervention (delivery) costs; and 5) Research costs.ResultsThe cost incurred for each completed ACD was A$13,980 in the hospital setting and A$1248 in the community setting. The cost incurred for each completed Conversation Card was A$7528 in the hospital setting and A$910 in the community setting.ConclusionsThe cost-consequence analysis does not support generalisation of the specified intervention within the hospital setting. The trial realised an estimated incremental cost per completed ACD of $1248, within the community setting. This estimate provides an additional benchmark against which decision-makers can assess the value of either 1) this approach towards the realisation of additional completed ACDs; and/or 2) the value of ACP and ACDs more broadly, when this estimate is positioned within the potential health outcomes and downstream health service implications that may arise for people with or without a completed ACD.Trial registrationThe study was retrospectively registered with the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001627246). The URL of the trial registry record.

Highlights

A growing body of international literature concurs that comprehensive and complex Advance Care Planning (ACP) programs involving specially qualified or trained healthcare professionals are effective in increasing documentation of Advance Care Directives (ACDs), improving compliance with patients’ wishes and satisfaction with care, and quality of care for patients and their families
The United States (US) government promoted Advance Directives (ADs) to encourage members of the public to be proactive about expressing their end-of-life treatment wishes and a statutory basis was established in all 50 states, under the Patient Self-Determination Act (PSDA) in 1991 [2]
The cost of the ACP Registered Nurse (RN) contracted to deliver the intervention are summarised in Additional File 3

Summary

Introduction

A growing body of international literature concurs that comprehensive and complex Advance Care Planning (ACP) programs involving specially qualified or trained healthcare professionals are effective in increasing documentation of Advance Care Directives (ACDs), improving compliance with patients’ wishes and satisfaction with care, and quality of care for patients and their families. There are variations in the terms, for example, ADs in US [2] and Germany [3], and Advance Care Directives (ACDs) or Advance Health Directives in Australia [4], the need for and importance of end-of-life care decisions have ever since grown and have been contributed by a variety of factors Among these are the ageing population [5,6,7], new life-sustaining technologies [8], rapidly increasing health-care costs [9], increasing patient awareness and demands for autonomy [10, 11], and the increasing numbers of people with chronic diseases in hospital and the wider community [12, 13]. It is ideal if ACDs are documented as a result of ACP when the person is still well and capable of making decisions [17]

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