Cost-effective Palliative Care Research Articles

Effectiveness and cost-effectiveness of palliative care in natural experiments: a systematic review

ContextInvestigators in palliative care rely heavily on routinely collected data, which carry risk of unobserved confounding and selection bias. ‘Natural experiments’ offer opportunities to generate credible causal treatment effect estimates...

Rationale and design of the EPCHF trial: the early palliative care in heart failure trial (EPCHF)

The progressive nature of heart failure (HF) coupled with high mortality and poor quality-of-life (QoL) mandates greater attention to palliative care (PC) as a routine component of HF management. Limited evidence exists from randomized controlled trials supporting the use of interdisciplinary palliative care in the progressive course of HF. The early palliative care in heart failure trial (EPCHF) is a prospective, controlled, nonblinded, multicenter study of an interdisciplinary palliative care intervention in 200 patients with symptomatic HF characterized by NYHA ≥ 2. The 12-month EPCHF intervention includes monthly consultations by a palliative care team focusing on physical and psychosocial symptom relief, attention to spiritual concerns and advance care planning. The primary endpoint is evaluated by health-related QoL questionnaires after 12 months of treatment. First the functional assessment of chronic illness therapy palliative care (FACIT-Pal) score evaluating QoL living with a chronic disease and second the Kansas City cardiomyopathy questionnaire (KCCQ) measuring QoL living with heart failure will be determined. Secondary endpoints are changes in anxiety/depression (HADS), symptom burden score (MIDOS), spiritual well-being functional assessment of chronic illness therapy spiritual well-being scale (FACIT-Sp), medical resource and cost assessment. EPCHF will help evaluate the efficacy and cost-effectiveness of palliative care in symptomatic HF using a patient-centered outcome as well as clinical and economic endpoints. EPCHF is funded by the Bundesministerium für Bildung und Forschung (BMBF, 01GY17).

The Cost-Effectiveness of Palliative Care: Insights from the PAL-HF Trial

BackgroundIn a randomized control trial, Palliative Care in Heart Failure (PAL-HF) improved heart failure–related quality of life, though cost-effectiveness remains unknown. The aim of this study was to evaluate the cost-effectiveness of the PAL-HF trial, which provided outpatient palliative care to patients with advanced heart failure. Methods and ResultsOutcomes for usual care and PAL-HF strategies were compared using a Markov cohort model over 36 months from a payer perspective. The model parameters were informed by PAL-HF trial data and supplemented with meta-analyses and Medicare administrative data. Outcomes included hospitalization, place of death, Medicare expenditures, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Simulated mortality rates were the same for PAL-HF and usual care cohorts, at 89.7% at 36 months. In the base case analysis, the PAL-HF intervention resulted in an incremental gain of 0.03 QALYs and an incremental cost of $964 per patient for an incremental cost-effectiveness ratio of $29,041 per QALY. In 1-way sensitivity analyses, an intervention cost of up to $140 per month is cost effective at $50,000 per QALY. Of 1000 simulations, the PC intervention had a 66.1% probability of being cost effective at a $50,000 willingness-to-pay threshold assuming no decrease in hospitalization. In a scenario analysis, PAL-HF decreased payer spending through reductions in noncardiovascular hospitalizations. ConclusionsThese results from this single-center trial are encouraging that palliative care for advanced heart failure is an economically attractive intervention. Confirmation of these findings in larger multicenter trials will be an important part of developing the evidence to support more widespread implementation of the PAL-HF palliative care intervention.

P054: The effectiveness of emergency department-based interventions for patients with advanced or end-stage illness: a systematic review

Introduction: Patients with advanced or end-stage illness frequently present to emergency departments (EDs), many of whom are in need of palliative care (PC). Emergency physicians have struggled in providing high quality care to these patients and there is a need to identify cost-effective PC interventions delivered in the ED to improve patient outcomes. The objective of this systematic review was to examine the effectiveness of ED-based PC interventions. Methods: A comprehensive search of nine electronic databases and grey literature sources was conducted to identify any comparative studies assessing the effectiveness of ED-based PC interventions to improve health outcomes of patients with advanced or end-stage illness. Two independent reviewers completed study selection, quality assessment, and data extraction. Differences were mediated via third-party adjudication. Relative risks (RR) with 95% confidence intervals (CIs) were calculated using a random effects model and heterogeneity (I2) was reported. Results: From 5882 potentially eligible citations, 12 studies were included. Two studies are currently on-going clinical trials, and as such, 10 studies were included in this analysis. The studies consisted of before-after studies (n = 5), RCTs (n = 4), and an observational cohort (n = 1). Interventions assessed among the included studies consisted primarily of ED-directed PC consultations (n = 6), while other studies assessed screening of patients with advanced or end-stage illness and PC needs (n = 2), education on PC for ED-staff (n = 1), and an ED-based critical care unit (n = 1). Infrequent reporting of important outcomes (e.g., Mortality, ED relapse) limited the ability of this review to conduct meaningful meta-analysis. There was no difference in patient mortality between two studies assessing ED-directed PC consultations (RR = 0.89; 95% CI: 0.71, 1.13; I2 = 0%). One before-after study (RR = 0.73; 95% CI: 0.47, 1.13) and two RCTs (RR = 2.19; 95% CI: 0.40, 11.92; I2 = 96%) did not identify significant differences in PC consultations intervention (implementation of ED-directed PC consultations) and control (usual care) patients. Conclusion: This review found limited evidence to support the recommendation of any particular ED-based intervention for patients presenting to the ED with advanced or end-stage illness. High quality studies and standardized outcome reporting are needed to better understand the impact of PC interventions in the ED setting.

Cost effectiveness in palliative care setting

PurposeThe purpose of this paper is to determine the cost effectiveness of palliative care on patients in a home health and hospice setting. Secondary data set was utilized to test the hypotheses of this study. Home health care and hospice care services have the potential to avert hospital admissions in patients requiring palliative care, which significantly affects medicare spending. With the aging population, it has become evident that demand of palliative care will increase four-fold. It was determined that current spending on end-of-life care is radically emptying medicare funds and fiscally weakening numerous families who have patients under palliative care during life-threatening illnesses. The study found that a majority of people registering for palliative and hospice care settings are above the age group of 55 years old.Design/methodology/approachDifferent variables like length of stay, mode of payment and disease diagnosis were used to filter the available data set. Secondary data were utilized to test the hypothesis of this study. There are very few studies on hospice and palliative care services and no study focuses on the cost associated with this care. Since a very large number of the USA, population is turning 65 and over, it is very important to analyze the cost of care for palliative and hospice care. For the purpose of this analysis, data were utilized from the National Home and Hospice Care Survey (NHHCS), which has been conducted periodically by the Centers for Disease Control and Prevention’s National Center for Health Statistics. Descriptive statistics, χ2 tests and t-tests were used to test for statistical significance at the p<0.05 level.FindingsThe Statistical Package for Social Sciences (SPSS) was utilized for this result. H1 predicted that patients in the age group of 65 years and up have the highest utilization of home and hospice care. This study examined various demographic variables in hospice and home health care which may help to evaluate the cost of care and the modes of payments. This section of the result presents the descriptive analysis of dependent, independent and covariate variables that provide the overall national estimates on differences in use of home and hospice care in various age groups and sex.Research limitations/implicationsThe data set used was from the 2007 NHHCS survey, no data have been collected thereafter, and therefore, gap in data analysis may give inaccurate findings. To compensate for this gap in the data set, recent studies were reviewed which analyzed cost in palliative care in the USA. There has been a lack of evidence to prove the cost savings and improved quality of life in palliative/hospice care. There is a need for new research on the various cost factors affecting palliative care services as well as considering the quality of life. Although, it is evident that palliative care treatment is less expensive as compared to the regular care, since it eliminates the direct hospitalization cost, but there is inadequate research to prove that it improves the quality of life. A detailed research is required considering the additional cost incurred in palliative/hospice care services and a cost-benefit analysis of the same.Practical implicationsWhile various studies reporting information applicable to the expenses and effect of family caregiving toward the end-of-life were distinguished, none of the previous research discussed this issue as their central focus. Most studies addressed more extensive financial effect of palliative and end-of-life care, including expenses borne by the patients themselves, the medicinal services framework and safety net providers or beneficent/willful suppliers. This shows a significant hole in the current writing.Social implicationsWith the aging population, it has become evident that demand of palliative/hospice care will increase four-fold. The NHHCS have stopped keeping track of the palliative care requirements after 2007, which has a negative impact on the growing needs. Cost analysis can only be performed by analyzing existing data. This review has recognized a huge niche in the evidence base with respect to the cost cares of giving care and supporting a relative inside a palliative/hospice care setting.Originality/valueThe study exhibited that cost diminishments in aggressive medications can take care of the expenses of palliative/hospice care services. The issue of evaluating result in such a physically measurable way is complicated by the impalpable nature of large portions of the individual components of outcome. Although physical and mental well-being can be evaluated to a certain degree, it is significantly more difficult to gauge in a quantifiable way, the social and profound measurements of care that help fundamentally to general quality of care.

Development and Implementation of a Pediatric Palliative Care Program in a Developing Country

Palliative care is recognized as an important component of care for children with cancer and other life-limiting conditions. In resource limited settings, palliative care is a key component of care for children with cancer and other life-limiting conditions. Globally, 98% of children who need palliative care live in low- or middle-income countries, where there are very few palliative care services available. There is limited evidence describing the practical considerations for the development and implementation of sustainable and cost-effective palliative care services in developing countries. Our aim is to describe the key considerations and initiatives that were successful in planning and implementing a hospital-based pediatric palliative care service specifically designed for a resource-limited setting. Bangabandu Sheikh Mujib Medical University (BSMMU) is a tertiary referral hospital in Bangladesh. Local palliative care services are very limited and focused on adult patients. In partnership with World Child Cancer, a project establishing a pediatric palliative care service was developed for children with cancer at BSMMU. We describe four key elements which were crucial for the success of this program: (1) raising awareness and sensitizing hospital administrators and clinical staff about pediatric palliative care; (2) providing education and training on pediatric palliative care for clinical staff; (3) forming a pediatric palliative care team; and (4) collecting data to characterize the need for pediatric palliative care. This model of a hospital-based pediatric palliative care service can be replicated in other resource-limited settings and can be expanded to include children with other life-limiting conditions. The development of pilot programs can generate interest among local physicians to become trained in pediatric palliative care and can be used to advocate for the palliative care needs of children.

Palliative Care in Vietnam: Long-Term Partnerships Yield Increasing Access

Palliative care began in Vietnam in 2001, but steady growth in palliative care services and education commenced several years later when partnerships for ongoing training and technical assistance by committed experts were created with the Ministry of Health, major public hospitals, and medical universities. An empirical analysis of palliative care need by the Ministry of Health in 2006 was followed by national palliative care clinical guidelines, initiation of clinical training for physicians and nurses, and revision of opioid prescribing regulations. As advanced and specialist training programs in palliative care became available, graduates of these programs began helping to establish palliative care services in their hospitals. However, community-based palliative care is not covered by government health insurance and thus is almost completely unavailable. Work is underway to test the hypothesis that insurance coverage of palliative home care not only can improve patient outcomes but also provide financial risk protection for patients' families and reduce costs for the health care system by decreasing hospital admissions near the end of life. A national palliative care policy and strategic plan are needed to maintain progress toward universally accessible cost-effective palliative care services.

Palliative Care Development in Tajikistan

Tajikistan's health system has undergone a series of complex changes associated with reforms aimed at the transition to a more sophisticated control mechanism, financing, and operation. As in many developing countries, there is an increase in morbidity and mortality from cancer and chronic diseases, including tuberculosis and HIV. Attention is needed by the state for the development of cost-effective palliative care that will be integrated into the existing public health system.A recent palliative care country needs assessment identified the following areas of work that need to be addressed for palliative care to be implemented:•educating and training of health care professionals,•raising public awareness about palliative care,•making essential palliative care medicines available,•developing the necessary regulatory documents for palliative care development,•developing educational curricula and materials,•integrating palliative care into the medical and nursing universities and schools,•creating models of palliative care services for home and inpatient facilities.

The International Association for Hospice and Palliative Care: Advancing Hospice and Palliative Care Worldwide

The International Association for Hospice and Palliative Care (IAHPC) is a membership-based organization dedicated to the development and improvement of hospice and palliative care worldwide. The mission of IAHPC is to improve the quality of life of adults and children with life-threatening conditions and their families. The vision of IAHPC is universal access to high-quality palliative care, integrated into all levels of health care systems in a continuum of care with disease prevention, early diagnosis, and treatment, to assure that any patient's or family caregiver's suffering is relieved to the greatest extent possible. IAHPC focuses on the advancement of four areas of palliative care: education, access to medicines, health policies, and service implementation. IAHPC works on three levels: at the grass roots, developing resources, and educational strategies that enable health workers to provide cost-effective palliative care; at the national level, working with government representatives to improve national policies to ensure adequate care and access to medicines; and at the international level, advocating with the UN organizations to ensure that access to palliative care and to essential medicines for palliative care and pain treatment is stipulated and incorporated as an obligation of member states.

Importance of Costs and Cost Effectiveness of Palliative Care

Importance of Costs and Cost Effectiveness of Palliative Care

Developing a Research Agenda for Integrating Palliative Care into Critical Care and Pulmonary Practice To Improve Patient and Family Outcomes.

Palliative care is a medical specialty and philosophy of care that focuses on reducing suffering among patients with serious illness and their family members, regardless of disease diagnosis or prognosis. As critical illness or moderate to severe pulmonary disease confers significant disease-related symptom burdens, palliative care and palliative care specialists can aid in reducing symptom burden and improving quality of life among these patients and their family members. The objective of this article is to review the existing gaps in evidence for palliative care in pulmonary disease and critical illness and to use an interdisciplinary working group convened by the National Institutes of Health and the National Palliative Care Research Center to develop a research agenda to address these gaps. We completed a narrative review of the literature concerning the integration of palliative care into pulmonary and/or critical care. The review was based on recent systematic reviews on these topics as well as a summary of relevant articles identified through hand search. We used this review to identify gaps in current knowledge and develop a research agenda for the future. We identified key areas of need and knowledge gaps that should be addressed to improve palliative care for patients with pulmonary and critical illness. These areas include developing and validating patient- and family-centered outcomes, identifying the key components of palliative care that are effective and cost-effective, developing and evaluating different models of palliative care delivery, and determining the effectiveness and cost-effectiveness of palliative care interventions. The goal of this research agenda is to encourage researchers, clinicians, healthcare systems, and research funders to identify research that can address these gaps and improve the lives of patients with pulmonary and critical illness and their family members.

CanSupport: a model for home-based palliative care delivery in India.

According to the 2014 WHO Global Atlas of Palliative Care, there is insufficient access to palliative care services worldwide, with the majority of unmet need in low- and middle-income countries. In India, there are major disparities in access to palliative care, with the majority of services being offered by non-governmental organizations (NGOs) scattered throughout the country. The barriers to expanding palliative care services in India are common to many lower- and middle-income countries-a lack of financial resources, a paucity of trained staff, and a focus on curative rather than comfort care. In this paper, we describe a model of palliative care being used by CanSupport, a non-governmental organization based in Delhi that was formed in 1996. They offer home-based services provided by multidisciplinary teams consisting of a physician, nurse, and social worker who are trained in palliative care. Data on patient demographics, services provided, and outcomes were collected retrospectively for patients treated by CanSupport for the year 2009-2010. Sources include CanSupport's population data and direct discussions with CanSupport staff. During the year 2009-2010, CanSupport served 746 patients, with an average of 10 home visits per patient. Only 29% of patients were referred from hospitals or physicians, with the rest being self-referred or referred from CanSupport's help line. Pain scales were administered on each visit and 31% of patients received morphine. Of the 514 patient deaths, 76% occurred at home and a majority of families received bereavement counseling for up to 6 months. CanSupport has shown that a home-based care model can be successful in India and is desired by patients at the end of life or with chronic illness. Their model of care saves the patients the cost of a hospital visit while still providing evaluation by staff with training in palliative care. In addition, the multidisciplinary nature of the teams allows for symptom management and emotional counseling for both the patients and their families. CanSupport has developed a way to provide reliable, cost-effective palliative care to patients that can serve as a model for building palliative care capacity in low- and middle-income countries.

Integrated pain and palliative medicine model.

Pain is one of the most common, distressing and feared symptom among cancer and other patients in need of palliative care. An estimated 25% of cancer patients and 25 million people die in pain each year. Effective pain and symptom management are the core elements of palliative care which aims at reducing suffering and improving quality of life (QOL) throughout the course of illness starting from diagnosis, in sync with curative treatments and at end of life. There is a prevailing shortage of manpower apt to deal with pain and providing cost-effective palliative care and with the rise of cancer, other chronic diseases and explosion of new life-prolonging therapeutic modalities, this 'Patient-pain and palliative physician' discrepancy is only going to increase, more so in developing countries. The need of the hour is to train all healthcare physicians and nurses especially those working in the field of chronic pain in principles of effective pain and symptom palliation, to integrate cancer pain and symptom management into existing pain management fellowships and to introduce a holistic pain and palliative care model at all levels of healthcare system. Simultaneously, of equal importance is to conduct research, evidence building and formulate policies and guidelines for meticulous symptom management among the diverse category of patients and diseases so as to have a personalized and individualistic approach to patient management. In this comprehensive review, we have pondered upon the need, advantages, barriers and recommendations to achieve ideal 'Integrated pain and palliative medicine' services, their equitable implementation and delivery to 'whomsoever in need of them'.

The Palliative Care in Heart Failure Trial: Rationale and design

The progressive nature of heart failure (HF) coupled with high mortality and poor quality of life mandates greater attention to palliative care as a routine component of advanced HF management. Limited evidence exists from randomized, controlled trials supporting the use of interdisciplinary palliative care in HF. PAL-HF is a prospective, controlled, unblinded, single-center study of an interdisciplinary palliative care intervention in 200 patients with advanced HF estimated to have a high likelihood of mortality or rehospitalization in the ensuing 6 months. The 6-month PAL-HF intervention focuses on physical and psychosocial symptom relief, attention to spiritual concerns, and advanced care planning. The primary end point is health-related quality of life measured by the Kansas City Cardiomyopathy Questionnaire and the Functional Assessment of Chronic Illness Therapy with Palliative Care Subscale score at 6 months. Secondary end points include changes in anxiety/depression, spiritual well-being, caregiver satisfaction, cost and resource utilization, and a composite of death, HF hospitalization, and quality of life. PAL-HF is a randomized, controlled clinical trial that will help evaluate the efficacy and cost effectiveness of palliative care in advanced HF using a patient-centered outcome as well as clinical and economic end points.

INITIATING DISCUSSION IN END OF LIFE CARE: CLINICIAN'S PERSPECTIVES

Background and AimsEngaging patients nearing the end of life in discussion about their subsequent treatment is regarded as a vital aspect to the provision of effective and cost-effective palliative care...

Making the (business) case for outpatient and home-based palliative care for cancer patients.

266 Background: Randomized controlled trials by Temel (2010) and Brumley (2003, 2007) have demonstrated the positive clinical, psycho-social, and utilization impact of providing early clinic or home-based palliative care (PC) concurrently with standard disease-focused treatment. Despite clear benefits, the growth of outpatient PC has been constrained by lack of clarity about the “business case” for hospitals or health systems to develop and fund PC services outside the inpatient setting. Methods: We will present findings from Virginia Commonwealth University (VCU) that provide a compelling quantification of the risks for hospitals to continue “business as usual” in this changing environment. Our approach measures quality, quantity, and costs of care for patients with cancer over a period of 6-12 months prior to death. Performance on some of these measures impact revenues in the prevailing fee-for-service reimbursement model; others are utilized in national, public ratings of quality; and still others influence organizational ability to compete in the population health management model that rewards quality and efficiency over time. Results: We used these data to highlight VCU Health System’s exposure to financial risks to create a strong business case for outpatient palliative care in which patient-centered and hospital-centered outcomes are aligned. This approach elevated our proposal to be included in a broader strategic initiative by our health system to manage complex care more efficiently, and to manage population health more proactively. Our analytic approach was then replicated by a diverse group of California provider groups who adopted or adapted the VCU model to advance their community-based palliative care programs as part of the California Health Care Foundation’s “Palliative Care Action Community” initiative. Conclusions: Our analytic model and articulation of the business case for community-based palliative care can help others to create and sustain quality-driven, patient-centered, cost-effective PC programs in their own institutions.

The location of community palliative care nurse specialist patient assessments: patient perceptions

BackgroundIt is current practice for the Community Palliative Care Nurse Specialist (CPCNS) service at Wigan & Leigh Hospice (WLH) to provide all assessments in patients' own homes. While the value...

How good is palliative care at following the MRC new guidance on complex interventions?

IntroductionImproved and cost-effective palliative care services are required to advance care for patients, their families and society. Service developments are however, often ad hoc with limited evaluation and little research...

Shackled: The Challenge of Caring for an Incarcerated Patient

Hospice care for inmates is widely recognized as an important way of providing efficient, cost-effective palliative care to a growing number of dying inmates. The case presented here is of a 34-year-old inmate who was admitted to a tertiary-care hospital for diagnostic tests and treatment of non-small cell lung cancer. While he was in the hospital, his clinical status rapidly deteriorated and it was clear that palliative care was most appropriate. Prison restrictions prevented the health care team from sharing the patient's clinical status with his family. He was forbidden many interventions that would have improved his comfort, such as watching television. The problems illustrated by this case occur many times in United States tertiary-care hospitals, and it is hoped that by describing it, more compassionate care for inmate patients, regardless of location, can be provided.