Abstract
BackgroundEconomic evaluations of advance care planning (ACP) in people with chronic kidney disease are scarce. However, past studies suggest ACP may reduce healthcare costs in other settings. We aimed to examine hospital costs and outcomes of a nurse-led ACP intervention compared with usual care in the last 12 months of life for older people with end-stage kidney disease managed with haemodialysis.MethodsWe simulated the natural history of decedents on dialysis, using hospital data, and modelled the effect of nurse-led ACP on end-of-life care. Outcomes were assessed in terms of patients’ end-of-life treatment preferences being met or not, and costs included all hospital-based care. Model inputs were obtained from a prospective ACP cohort study among dialysis patients; renal registries and the published literature. Cost-effectiveness of ACP was assessed by calculating an incremental cost-effectiveness ratio (ICER), expressed in dollars per additional case of end-of-life preferences being met. Robustness of model results was tested through sensitivity analyses.ResultsThe mean cost of ACP was AUD$519 per patient. The mean hospital costs of care in last 12 months of life were $100,579 for those who received ACP versus $87,282 for those who did not. The proportion of patients in the model who received end-of-life care according to their preferences was higher in the ACP group compared with usual care (68% vs. 24%). The incremental cost per additional case of end-of-life preferences being met was $28,421. The greatest influence on the cost-effectiveness of ACP was the probability of dying in hospital following dialysis withdrawal, and costs of acute care.ConclusionOur model suggests nurse-led ACP leads to receipt of patient preferences for end-of-life care, but at an increased cost.
Highlights
Advance care planning (ACP) supports people to consider and communicate their future treatment preferences in the context of their own goals and values
The proportion of patients in the model who received end-of-life care according to their preferences was higher in the advance care planning (ACP) group compared with usual care (68% vs. 24%)
Our model suggests nurse-led ACP leads to receipt of patient preferences for end-of-life care, but at an increased cost
Summary
Advance care planning (ACP) supports people to consider and communicate their future treatment preferences in the context of their own goals and values. ACP has been associated with greater adherence to treatment preferences at end-of-life and greater incidence of patients withdrawing from dialysis in accordance with their preferences compared to controls [12, 13]. These findings have not been replicated in large scale, high quality randomized controlled trials [14]. Economic evaluations of advance care planning (ACP) in people with chronic kidney disease are scarce. We aimed to examine hospital costs and outcomes of a nurse-led ACP intervention compared with usual care in the last 12 months of life for older people with end-stage kidney disease managed with haemodialysis
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