Economic (gross cost) analysis of systematically implementing a programme of advance care planning in three Irish nursing homes.

Ronan O’Sullivan,Brian Daly,Nicola Cornally,Ciara Mcglade,Carol Fizgerald,D William Molloy,Anton Svendrovski,Cillian Twomey,Rónán O’Caoimh,Aileen Murphy

doi:10.1186/s13104-016-2048-9

Abstract

BackgroundAlthough advance care planning (ACP) and the use of advanced care directives (ACD) and end-of-life care plans are associated with a reduction in inappropriate hospitalisation, there is little evidence supporting the economic benefits of such programmes. We assessed the economic impact (gross savings) of the Let Me Decide (LMD) ACP programme in Ireland, specifically the impact on hospitalisations, bed days and location of resident deaths, before and after systematic implementation of the LMD-ACP combined with a palliative care education programme.MethodsThe LMD-ACP was introduced into three long-term care (LTC) facilities in Southern Ireland and outcomes were compared pre and post implementation. In addition, 90 staff were trained in a palliative care educational programme. Economic analysis including probabilistic sensitivity analysis was performed.ResultsThe uptake of an ACD or end-of-life care post-implementation rose from 25 to 76 %. Post implementation, there were statistically significant decreases in hospitalisation rates from baseline (hospitalisation incidents declined from 27.8 to 14.6 %, z = 3.96, p < 0.001; inpatient hospital days reduced from 0.54 to 0.36 %, z = 8.85, p < 0.001). The percentage of hospital deaths also decreased from 22.9 to 8.4 %, z = 3.22, p = 0.001. However, length of stay (LOS) increased marginally (7–9 days). Economic analysis suggested a cost-reduction related to reduced hospitalisations ranging between €10 and €17.8 million/annum and reduction in ambulance transfers, estimated at €0.4 million/annum if these results were extrapolated nationally. When unit costs and LOS estimates were varied in scenario analyses, the expected cost reduction owing to reduced hospitalisations, ranged from €17.7 to €42.4 million nationally.ConclusionsImplementation of the LMD-ACP (ACD/end-of-life care plans combined with palliative care education) programme resulted in reduced rates of hospitalisation. Despite an increase in LOS, likely reflecting more complex care needs of admitted residents, gross costs were reduced and scenario analysis projected large annual savings if these results were extrapolated to the wider LTC population in Ireland.

Highlights

Advance care planning (ACP) and the use of advanced care directives (ACD) and end-of-life care plans are associated with a reduction in inappropriate hospitalisation, there is little evidence supporting the economic benefits of such programmes
The current study evaluated the feasibility of systematically implementing the Let Me Decide (LMD)-advance care planning (ACP) programme in three Irish long term care (LTC) facilities together with a palliative care workshop
The rationale for using unit costs per episode, which results in projected savings of approximately €17.8 million per year, if the LMDACP programme were introduced nationwide in Ireland, lies in the planned shift towards activity based costing envisaged for the Irish healthcare system, whereby costs will be based on episodes of care

Summary

Introduction

Advance care planning (ACP) and the use of advanced care directives (ACD) and end-of-life care plans are associated with a reduction in inappropriate hospitalisation, there is little evidence supporting the economic benefits of such programmes. An end-of-life care plan is created between individuals who lack capacity, their family, and healthcare professionals to plan for future healthcare decisions It is not legally binding, rather a road map to guide the decision making process. ACP including the creation of either an ACD or end-of-life care plan offers a unique opportunity to optimise care, promote autonomy, empower patients and maximise resource use [7]. It promotes collaborative care, reduces heath inequalities by increasing access to palliative care, improves satisfaction with end-of-life care and facilitates choice of place of death [8,9,10,11]

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