Cost-Effectiveness of Palliative Team Care For Patients Nearing End-Of-Life Society for Medical...
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Transcript of 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
Chronic conditions in LTC home
Stable conditions at home
Stable conditions at home with HOME CARE
Model Structure
Palliative prognosis required inpatient care
Palliative prognosis required acute care in ER
Acute illness required inpatient care
Acute illness required ER care
Chronic conditions in LTC home
Palliative prognosis in LTC home
Stable conditions at home
Palliative prognosis at home with home care
Stable conditions 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
Acute illness required inpatient care
Acute illness required ER care
Chronic conditions in LTC home
Palliative prognosis in LTC home
Stable conditions at home
Palliative prognosis at home with home care
Stable conditions 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
Systematic ReviewsLinked Health Admin.Micro-costing studiesHealth utility studies
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)
Systematic ReviewsLinked Health Admin.Micro-costing studiesHealth utility studies
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)
Systematic ReviewsLinked Health Admin.Micro-costing studiesHealth utility studies
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
Systematic ReviewsLinked Health Admin.Micro-costing studiesHealth utility studies
Cost of Palliative Team Care
• $19 per patient per day• Average service duration: 5
months
Systematic ReviewsLinked Health Admin.Micro-costing studiesHealth utility studies
Cost of Palliative Team Care
Additional nursing services
Medication/transportation/equipment charges
Palliative care physician consultations
Others
Out-of-Pocket Expenses and Unpaid Care Costs
• Diary-Based Micro-Costing Study (Coyte et al. 2013)
• n=119 EOL cancer patients in Toronto
• Unpaid care costs due to time lost • Paid market labor, • Household work, • Leisure
Systematic ReviewsLinked Health Admin.Micro-costing studiesHealth utility studies
Out-of-Pocket Expenses and Unpaid Care Costs
12 11 10 9 8 7 6 5 4 3 2 10
5,000
10,000
15,000
20,000
25,000
Monthly unpaid care costMontly out-of-pocket expenses
Months Before Death
Cost
($)
Health Utility EstimatesSelected Studies
• Palliative cancer patients • Patients at home (± home care), long-
term care • Patients in ER, hospital and ICU
Systematic ReviewsLinked Health Admin.Micro-costing studiesHealth utility studies
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
Systematic ReviewsLinked Health Admin.Micro-costing studiesHealth utility studies
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?