COST-EFFECTIVENESS ANALYSIS OF PALLIATIVE TEAM CARE FOR PATIENTS NEARING END-OF-LIFE
Methods: Study design: cost-effective and cost-utility analyses from the societal and health-care payer’s perspectives. Target population: patients nearing end-of-life (according to observed population-based setting-specific patterns of palliative services) over the last year of life (a one-year time horizon) and their primary informal caregivers. Comparators: “usual care” with current palliative services, “in-home palliative team care” with service provision at home or in long-term care home, “in-patient palliative team care”, and “comprehensive palliative team care” by a single team with care coordination across settings.
We included health care costs (2013 Canadian dollars; including costs of home care, long-term care, hospital care, outpatient services, drugs, and physician billings), and additional costs of private insurance, out-of-pocket expenses, and time lost from paid work. Effectiveness measures included days at home and percentage dying at home (base case analysis), and quality-adjusted life days (QALD; sensitivity analysis).
We developed a state-transition microsimulation model to simulate palliative care needs by the target population. Model inputs were obtained from an end-of-life cohort of Ontarian decedents (n= 256,284) assembled from linked health administration databases (2007-2009), systematic reviews of randomized controlled trials evaluating palliative team care, and published literature. We conducted one-way and probabilistic sensitivity analyses.
In-home palliative team care dominated usual care, with an expected $4,424 healthcare cost saving (via reduced ER visits and hospital admissions), approximately 5.8 more days at home, 10.3% more home deaths, and 0.47 QALDs gained [with a 72% likelihood of being cost-effective at $50k per QALY]. In-patient team care appeared to dominate usual care (corresponding values: $1,643, 0.65 days, -0.2% and 0.27 QALDs [38%]). Comprehensive palliative team care was associated with $527 additional cost, 1.4 more days at home, 1.7% more home deaths, and 2.65 QALDs gained, corresponding to an estimated cost of approximately $72k per QALY [32%]. Results from the societal perspective were similar, mainly due to a lack of data regarding the team’s effects on quality-of-life, time and costs associated with care giving.
Conclusions: In-home palliative team care is cost-effective. Firm conclusions are not possible regarding the cost-effectiveness of in-patient and comprehensive team care.