Tuesday, October 21, 2014: 10:30 AM

Ba' Pham, MSc, PhD (c)1, Robert A. Fowler, MD, MSc2, Peter Tanuseputro, MD, MHSc3, Douglas Manuel, MD, MSc4, Nancy Sikich, MSc5, Shamara Baidoobonso, MSc, PhD5, Petros Pechlivanoglou, PhD1, Les Levin, MD, MSc5 and Murray D. Krahn, MD, MSc1, (1)Toronto Health Economics and Technology Assessment (THETA) Collaborative, University of Toronto, Toronto, ON, Canada, (2)Sunnybrook Health Sciences Center, Toronto, ON, Canada, (3)Institute for Clinical Evaluative Sciences, Toronto, ON, Canada, (4)Ottawa Hospital Research Institute, Ottawa, ON, Canada, (5)Health Quality Ontario, Toronto, ON, Canada
Purpose: Care at end-of-life consumes approximately 9% of the Ontario health-care budget. To support policy development, we evaluated the cost-effectiveness of palliative team care.

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.