Table 1:
Results of Economic Literature Review—Summary
| Name, Year | Study Design, Perspective | Population | Interventions | Results | Authors’ Conclusions | Limitations | Applicability | ||
|---|---|---|---|---|---|---|---|---|---|
| Health Outcomes | Costs | Cost-Effectiveness | |||||||
| Gomes et al, 2013 (15) | Systematic review of the effectiveness/cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers; cost-effectiveness data were reported in 5 RCTs and 1 controlled before-after study Perspective: societal (16;17) or health care perspective (18–21) | Patients with advanced illness and their family and caregivers (n = 2,047 patients and 1,678 caregivers) | Home palliative care services Usual care with various levels of primary care services, home health services, acute care services, and hospice care | Incremental health outcomes between interventions and controls varied across the 6 included studies | Incremental costs between interventions and controls varied across the 6 included studies | Intervention was cost-effective according to 2 included RCTs. (16;21) It was unclear whether the intervention was cost-effective in the other 4 studies (17–19;22) | More work is needed to study the cost-effectiveness of home palliative care services | Only 2 of the 6 included studies fulfilled the time criteria for this literature review (studies published between 2000 and 2009) | Given the systematic approach of the study, the conclusions are likely to be robust and applicable to similar patients in Ontario |
| Higginson et al, 2009 (16) | CEA; RCT of 12 weeks Perspective: societal, 2005 UK pounds | Patients with severe multiple sclerosis (n = 52) | Fast-track—immediate referral to a palliative care team (n = 26) Usual care (n = 26) | Patient outcomes: no significant differences in POS. A trend in pain reduction was reported for the intervention group, but pain increased for the usual care group Caregivers’ outcomes: intervention group had a significantly lower caregiver burden | Mean costs were £1,789 (95% CI £5,224–£1,902) lower for the intervention group | In-home palliative care significantly increased patient satisfaction while reducing use of medical services and costs of medical care at the end of life | Short-term palliative care for people with severe multiple sclerosis and their caregivers was cost-effective and warranted further study | Small pilot RCT | Intervention effect was studied in patients with severe multiple sclerosis only, limiting the applicability of the trial results to patients with EoL conditions |
| Goldfeld et al, 2013 (23) | Two CUAs in 1 study; prospective cohort study of residents from 22 nursing homes, 18 months’ follow-up Perspective: US Medicare; 2007 US $ | Nursing home residents with advanced dementia (n = 323) | CUA 1 No DNH order (n = 144) DNH order (n = 124) CUA 2 Hospitalization for suspected pneumonia (n = 18) No hospitalization (n = 113) | CUA 1 DNH associated with incremental survival of 3.7 QALDs CUA 2 Hospitalization associated with incremental reduction in survival of 9.7 QALDs | CUA 1 DNH associated with an incremental increase in Medicare expenditures of $5,972 CUA 2 Hospitalization associated with an incremental increase in Medicare expenditures of $3,697 | CUA 1 DNH associated with an estimated cost of approximately $589,000 per QALY gained CUA 2 Hospitalization dominated by no hospitalization | Treatment strategies favouring hospitalization for nursing home residents with advanced dementia were not cost-effective | Analyses based on data from an observational study, with a possibility of unmeasured confounding factors | Likely to be applicable to LTC residents in Ontario |
| Lowery et al, 2013 (24) | CEA and CUA (sensitivity analysis); CEA and CUA based upon a decision tree, 6-month time horizon Perspective: US Medicare; 2012 US$ | Patients with recurrent platinum-resistant ovarian cancer | Early referral to a palliative medicine specialist (EPC) plus usual care Usual care only | EPC associated with significant reductions in ED visits, hospitalizations, and chemotherapy admissions | EPC associated with a cost-saving of $1,285 per patient | EPC was dominant or cost-effective at $50,000 per QALY, unless the cost of outpatient EPC exceeded $2,400 | EPC had the potential to reduce costs associated with EoL care in patients with ovarian cancer | Unclear whether the health outcome estimates derived from an RCT of patients with metastatic NSCLC are applicable to patients with recurrent ovarian cancer in the current study | Overall, the methods were appropriate; likely to be applicable to similar patients in Ontario |
| Pace et al, 2012 (25) | CEA; observational study Perspective: not stated, but included only hospital costs for the last 2 months of life; Euros | Patients with primary brain tumours (n = 143) | Group 1 assisted at home (n = 72) Group 2 not assisted at home (n = 71) | Hospitalization rate of Group 1 was lower than that of Group 2 (16.7% vs. 38%, P = 0.001) | Costs of hospitalization differed substantially: €517 (95% CI €512–522) in Group 1 vs. €24,076 €24,040–24,112) in Group 2 | Group 1 was dominant compared to Group 2 | Home-care models may represent an alternative to in-hospital care for the management of brain tumour patients and may improve EoL quality of care | Unclear whether the 2 groups were similar with respect to factors that influence inputs into the CEA (e.g., re-hospitalization rates and hospital days) | Unclear whether the study results and the authors’ conclusions were valid |
| Ljungman et al, 2013 (26) | CUA; retrospective analysis of a population-based cohort Perspective: health care payer, 1,2,5 years for different patient groups; 2011 Euros | A population-based cohort of patients with exocrine pancreatic adenocarcinoma during 1998–2005 from 1 hospital (n = 444) | Patients with personalized palliative care (n = 21) Patients on standard palliative care for pain management (n = 284) Patients with pancreatic carcinoma resected for cure (n = 139) | QALYs for 1 year from diagnosis were 0.2 (95% CI 0.17–0.23) in patients on palliative care and 0.48 (95% CI 0.44–0.54) in resection patients | Total direct health care costs were 50% in patients on palliative care vs. costs for surgical resections (€23,701 and €50,950, respectively) | Costs per QALY were €118,418 for patients on palliative care and €106,146 for resection patients (95% CI €103,048–€139,418 and €94,352–€115,795, respectively) | Optimized palliative care of patients with exocrine pancreatic carcinoma had costs per achieved utility similar to those for surgical resections aimed at cure | Analysis involved patient groups with very different prognoses; it's unclear whether it was valid to compare the costs and health consequences of palliative patients to those of patients undergoing tumour resection for cure | Results may not be interpretable due to choices of comparators |
Abbreviations: CEA, cost-effectiveness analysis; CI, confidence interval; CUA, cost-utility analysis; DNH, do-not-hospitalize; ED, emergency department; EoL, end-of-life; EPC, early palliative care; LTC, long-term care; NSCLC, non-small cell lung cancer; POS, Palliative Outcome Scale; QALD, quality-adjusted life-day; QALY, quality-adjusted life-year; RCT, randomized controlled trial.