cost-effectiveness of palliative team care for patients nearing end-of-life society for medical...

Cost-Effectiveness of Palliative Team Care For

Patients Nearing End-Of-Life

Society for Medical Decision Making36st Annual Meeting – Miami, Florida

October 18 - 22, 2014

ContributorsBa’ Pham, PhD Robert Fowler, MD, MSc

Peter Tanuseputro, MD, MSc

Douglas Manuel, MD, MSc

Nancy Sikich, MSc Shamara Baidoobonso, PhD

Petros Pechlivanoglou, PhD

Les Levin, MD, MSc

Murray Krahn, MD, MSc

On behalf of the Health Quality Ontario Expert Panel on End-of-Life Care

End-of-Life Care

• EOL care consumes ~9% of the Ontario healthcare budget

• Recent policy review for quality improvement

• Evidence is needed for policy development• Support patients according to

their wishes and preferences

Objectives• To evaluate the cost-effectiveness

of in-home palliative team care for • EOL patients and • their family.

Palliative Team Care

• Timely identify palliative patients• Need assessment• Care coordination• 24/7 access• Symptom, social support

interventions• Psycho-spiritual care• Bereavement care

Methods

Overview• Model-based CEA• Perspectives• Healthcare payer’s (base case)

• Societal

• Time horizon: Last year of life • Costs in 2014 Canadian dollar

Ontario Palliative Care Decision Model

• Markov microsimulation model• Cycle from 1 to 365 days• Cohort of decedents 76 years of age

• Simulate care transitions • Project costs and health

outcomes• Percentage dying at home• Days at home• QALY

Model Structure

Chronic conditions in LTC home

Stable conditions at home

Stable conditions at home with HOME CARE

Model Structure

Acute illness required inpatient care

Acute illness required ER care




Model Structure

Palliative prognosis required inpatient care

Palliative prognosis required acute care in ER




Palliative prognosis in LTC home


Palliative prognosis at home with home care


Model Structure

Palliative prognosis required inpatient care

Palliative prognosis in non-home hospice

Palliative prognosis in palliative care ward or ALC

Palliative prognosis in complex continuing care

Palliative prognosis required acute care in ER




Palliative prognosis in LTC home


Palliative prognosis at home with home care


Data Sources

• Systematic reviews • Study with linked health admin data• Micro-costing studies• In-home Palliative Team Care• Unpaid care costs

• Selected studies reporting health utility• Additional literature reviews

Systematic ReviewsLinked Health Admin.Micro-costing studiesHealth utility studies

Clinical Evidence

• Cochrane Systematic Review • Gomes et al. 2013

• Health Quality Ontario Systematic Review• Sikich et al. 2014


Effects of Palliative Team Care

# RCTs

Outcomes Outcome Measures

Rx versus CtrlEstimate (95% CI)

4 Patient’s QOL Effect size

0.25 (0.05, 0.44)

6 Hosp. admission

Risk ratio 0.81 (0.67, 0.98)

5 Hospital days LOS -2.88 (-5.24, -0.52)


Effects of Palliative Team Care

# RCTs

Outcomes Outcome Measures

Rx versus CtrlEstimate (95% CI)

4 Patient’s QOL Effect size

0.25 (0.05, 0.44)

6 Hosp. admission

Risk ratio 0.81 (0.67, 0.98)

5 Hospital days LOS -2.88 (-5.24, -0.52)

4 ER visit Rate ratio

0.87 (0.70, 1.08)

1 ICU admission Rate ratio

0.78 (0.53, 1.17)

1 ICU days LOS -0.32 (0.83, 1.01)


Ontario Usual Care

• Study with linked health admin. data at ICES*

• Cohort of decedents(n=256,284; 2007-2009)

• Care received over the previous 12 months• Health care costs • Home care, long-term, acute and palliative

care;• Outpatient services; • Drugs/devices; • Physician, non-physician and laboratory billingsSystematic Reviews

Linked Health Admin.Micro-costing studiesHealth utility studies

*Ontario Institute for Clinical Evaluative Sciences

Timing of Palliative Care

No palliative care

Palliative within 6-12 mths of

death

Palliative within 3-6 mths of

death

Palliative within 3 mths of death

0

0.1

0.2

0.3

0.4

0.5

0.6

LTC Home Care Acute Care

Prop

ortio

n

12 11 10 9 8 7 6 5 4 3 2 10.00

0.01

0.02

0.03

0.04

From LTC From home

Months Before Death

Daily R

ate

of

ER

vis

tsTransition Rates, e.g., ER Visits

Healthcare Resources Utilization

ER: Emergency Room. LTC: Long-Term Care.

ER Home Care Hospice Care* Hospital Care LTC0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Observed ICES dataProjected data from Ontario Palliative Care Decision Model

Prop

ortio

n W

ith ≥

1 U

se

Cost of Palliative Team Care

• Micro-costing study (Klinger et al. 2011)

• Resource utilization and costs• n=95 Ontario EOL patients



• $19 per patient per day• Average service duration: 5

months



Additional nursing services

Medication/transportation/equipment charges

Palliative care physician consultations

Others

Out-of-Pocket Expenses and Unpaid Care Costs

• Diary-Based Micro-Costing Study (Coyte et al. 2013)

• n=119 EOL cancer patients in Toronto

• Unpaid care costs due to time lost • Paid market labor, • Household work, • Leisure


Out-of-Pocket Expenses and Unpaid Care Costs

12 11 10 9 8 7 6 5 4 3 2 10

5,000

10,000

15,000

20,000

25,000

Monthly unpaid care costMontly out-of-pocket expenses

Months Before Death

Cost

($)

Health Utility EstimatesSelected Studies

• Palliative cancer patients • Patients at home (± home care), long-

term care • Patients in ER, hospital and ICU


Quality of Life - PatientsPalliative Team Care

At home (0.78)

At home with home care (0.59)

ER visit (=0.01)Hospital stay (=0.06) ICU stay (=0.10)

* Sources: Van den Hout et al. 2006 study, including palliative cancer patients

Health Utility – FamilyA Selected Study

• Collateral effects on family and caregivers

• Spillover effects are measurable (Prosser et al. 2014)

• Standard gamble technique


Estimated Spillover Disutility: ~0.1

Results

Effectiveness Estimates

* In-Home Palliative Team Care

Usual Care PTC Incr.

Dying at home 46% 51% 5%

Days at home 337 343 6

Base Case Analysis

Notes: PTC In-Home Palliative Team Care. NMB: Net Monetary Benefit at $50,000 per QALY

Usual Care

PTC Incremental

Incr. NMB

Cost 49,964 46,788 -3,175 4,662

QALY 0.59 0.62 0.03

One-Way Sensitivity Analysis

Change in ICU days with in-home PTC

Adjusting hospitalization rate | ER visit rate

Rate Ratio of ICU admission

Relative Risk of hospitalization

Rate Ratio of ER visits

Daily cost of in-home PTC

Change in hospital days with in-home PTC

0 1000 2000 3000 4000 5000 6000 7000 8000 9000

0.51

0

1.17

0.98

1.08

$30

-0.52

6 -1.15

1

0.53

0.67

0.70

$10

-5.24

Incremental NMB of In-Home PTC versus Usual Care ($)**Net monetary benefit at $50,000 per QALY

Daily Cost of Palliative Team Care

0 10 20 30 40 50

-8000

-6000

-4000

-2000

0

2000

4000

6000

8000

10000

12000

Daily Cost of In-Home Palliative Team Care ($)

Net

Ben

efi

t ($

) of

PTC

vers

us U

su

al

Care

Threshold: $42

Base: $19

Cost per patient: $4,423Average service duration: 8 months

Probabilistic Sensitivity Analysis

Note: PSA with n= 20,000

Unpaid Care Cost Borne by Family

Healthcare Payer's Perspective

Societal Perspective0

10000

20000

30000

40000

50000

60000

70000

80000

Usual CareIn-Home Palliative Team Care

Cost

($

)

Quality of Life of Patients and Spillover Effect on Family

Patients Patients + Spillover

Patients + Spillover

Patients + Spillover

0.0000

0.1000

0.2000

0.3000

0.4000

0.5000

0.6000

0.7000

Usual Care In-Home PTC

QA

LY

Conclusion

• In-Home Palliative Team Care is likely to be a dominant strategy

• The associated costs and consequences on the family is uncertain.• Additional data are needed to reduce

this uncertainty.

Limitations

• Impact on time to death was not considered

• QALY framework may not be appropriate for EOL care

Thank you!Comments and Questions?

cost-effectiveness of palliative team care for patients nearing end-of-life society for medical...

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