Costs of terminal patients who receive palliative care or usual care in different hospital wards

Comparison of direct medical care costs between patients receiving care in a designated palliative care unit and the usual care units

AIM

The need for palliative services is increasing throughout Thailand. A few palliative care units have been established in the nation so far. An economic evaluation of palliative care units has never been explored. This study compared between the medical costs of terminally ill patients receiving palliative care in a palliative care unit and the usual care units during their final admissions.

METHODS

This study was a retrospective observational study comparing the costs of care for patients who died in a tertiary hospital. The study group comprised patients who died in a palliative care unit, then matched with deceased patients from other units by diagnosis-related groups. Patients not indicating of having received palliative care in the medical records were excluded. The direct medical costs of the patients' care and their data were collected from the finance department database and by medical chart review. Data were entered into the SPSS statistical database. The costs of the control group were calculated from the day when palliative care was initiated RESULTS: The total cost of care was significantly lower in the palliative care unit by 45 percent. The cost reduction notably was from the shorter length of stay and lower expenditure on medication and investigations in the palliative care unit. The utilization of aggressive treatment was higher in the usual units.

CONCLUSIONS

The palliative care unit was associated with cost savings in caring for terminally ill patients in a tertiary hospital in Thailand.

Palliative Care Consultation in the Intensive Care Unit Reduces Hospital Costs: A Cost-Analysis

BACKGROUND

Palliative care aims to improve or maintain quality of life for patients with life-limiting or life-threatening diseases. Limited research shows that palliative care is associated with reduced intensive care unit length of stay and use of high-cost resources.

METHODS

This was an observational, non-experimental comparison group study on all patients 18 years or older admitted to any intensive care unit (ICU) at Memorial Hermann - Texas Medical Center for 7 to 30 days from August 2013 to December 2015. Length of stay (LOS) and hospital costs were compared between the treatment group of patients with palliative care in the ICU and the control group of patients with usual care in the ICU. To adjust for confounding of the palliative care consultation on LOS and hospital cost, an inverse probability of treatment weighted method was conducted. Generalized linear models using gamma distribution and log link were estimated. All costs were converted to 2015 US dollars.

RESULTS

Mean LOS was 13 days and mean total hospital costs were USD 58,378. In adjusted and weighted analysis, LOS for the treatment group was 8% longer compared to the control group. The mean total hospital cost was estimated to decrease by 21% for the treatment group versus the control group. We found a reduction of USD 33,783 in hospital costs per patient who died in the hospital and reduction of USD 9113 per patient discharged alive.

CONCLUSION

Palliative care consultation was associated with a reduction in the total cost of hospital care for patients with life-limiting or life-threatening diseases.

The association between varying levels of palliative care involvement on costs during terminal hospitalizations in Canada from 2012 to 2015

Background

Inpatient palliative care is associated with lower inpatient costs; however, this has yet to be studied using a more nuanced, multi-tiered measure of inpatient palliative care and a national population-representative dataset. Using a population-based cohort of Canadians who died in hospital, our objectives were to: describe patients’ receipt of palliative care and active interventions in their terminal hospitalization; and examine the relationship between inpatient palliative care and hospitalization costs.

Methods

Retrospective cohort study using data from the Discharge Abstract Database in Canada between fiscal years 2012 and 2015. The cohort were Canadian adults (age ≥ 18 years) who died in hospital between April 1st, 2012 and March 31st, 2015 (N = 250,640). The exposure was level of palliative care involvement defined as: medium-high, low, or no palliative care. The main measure was acute care costs calculated using resource intensity weights multiplied by the cost of standard hospital stay, represented in 2014 Canadian dollars (CAD). Descriptive statistics were represented as median (IQR), and n(%). We modelled cost as a function of palliative care using a gamma generalized estimating equation (GEE) model, accounting for clustering by hospital.

Results

There were 250,640 adults who died in hospital. Mean age was 76 (SD 14), 47% were female. The most common comorbidities were: metastatic cancer (21%), heart failure (21%), and chronic obstructive pulmonary disease (16%). Of the decedents, 95,450 (38%) had no palliative care involvement, 98,849 (38%) received low involvement, and 60,341 (24%) received medium to high involvement. Controlling for age, sex, province and predicted hospital mortality risk at admission, the cost per day of a terminal hospitalization was: $1359 (95% CI 1323: 1397) (no involvement), $1175 (95% CI 1146: 1206) (low involvement), and $744 (95% CI 728: 760) (medium-high involvement).

Conclusions

Increased involvement of palliative care was associated with lower costs. Future research should explore whether this relationship holds for non-terminal hospitalizations, and whether palliative care in other settings impacts inpatient costs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06335-1.

Were the hospital bed reductions proposed by English Clinical Commissioning Groups (CCGs) in the sustainability and transformation plans (STPs) achievable? Insights from a new model to compare international bed numbers

A new model for hospital bed numbers which adjusts for end-of-life care and age structure is used to demonstrate that England has 20% fewer occupied beds than the other countries in the United Kingdom. It also shows that occupied beds in English Clinical Commissioning Groups (CCGs) lie parallel to a line of equivalence with New Zealand and Singapore. This is despite New Zealand and Singapore having invested many years into developing integrated care, while England has not. In addition, England has around half the number of nursing home beds per death available in these two countries. Large bed reductions proposed in the sustainability and transformation plans were likely to have been manipulated to meet financial cost-saving targets rather than a result of genuine modelling of demand. The ways in which bed demand models can be manipulated to give whatever answer is required are discussed. Trends in occupied acute medical beds in England over the past 20 years show no real reduction, despite a large reduction in available beds. This has resulted in daytime occupancy for adult beds being close to 100% and with resulting queues to admission. The ways to improve the small-area application of the model including the use of deprivation or social groups are discussed.

An analysis of the costs of treating aged patients in a large clinical hospital in Poland under the pressure of recent demographic trends

INTRODUCTION

The aging of modern societies increases the general healthcare burden due to the growing demand for inpatient services, which lack adequate financing.

MATERIAL AND METHODS

Data concerning the costs of 312,250 hospitalizations at University Clinical Hospital in Wrocław, Poland in the years 2012-2015 were analyzed according to the age of the patients: below 65 years and 65 years and older, with subgroups (65-74, 75-84 and 85 years and older).

RESULTS

The mean length of stay (LOS) differed significantly for patients below 65 years and for patients 65 years old or older (3.5 vs. 4.7 person-days); over the 4 years covered by our data, these increased by 0.4 person-days, mostly among patients 85 years and older (by 0.7 person-days). The mean direct cost of hospitalization differed significantly for patients below 65 years and those 65 years or older (PLN 4,907.12 vs. PLN 6,357.15). The mean cost of laboratory tests and radiologic diagnostics was significantly higher among those in the 65+ group, and the difference had a rising trend. The differences between age groups in cost-related hospitalization characteristics and direct hospitalization costs that have been suggested by the medical literature have also been confirmed in Poland.

CONCLUSIONS

The mean hospitalization costs of patients aged 65 years and older in Poland are higher than for younger patients due to longer LOS and more complex and expensive treatment, especially laboratory and radiologic diagnostics, which is increasingly common in the oldest age groups. This demands an urgent systemic solution, especially in terms of adjusted financing of elderly patients' hospital treatment.

Which Cost Components Influence the Cost of Palliative Care in the Last Hospitalization? A Retrospective Analysis of Palliative Care Versus Usual Care at a Swiss University Hospital

CONTEXT

Although the number of studies on the economic impact of palliative care (PC) is growing, the great majority report costs from North America.

OBJECTIVES

We aimed to provide a comprehensive overview of PC hospital cost components from the perspective of a European mixed funded health care system by identifying cost drivers of PC and quantifying their effect on hospital costs compared to usual care (UC).

METHODS

We performed a retrospective, observational analysis examining cost data from the last hospitalization of patients who died at a large academic hospital in Switzerland comparing patients receiving PC vs. UC.

RESULTS

Total hospital costs were similar in PC and UC with a mean difference of CHF -2777 [95% CI -12,713 to 8506, P = 0.60]. Average costs per day decreased by CHF -3224 [95% CI -3811 to -2631, P < 0.001] for PC patients with significant reduction of costs for diagnostic intervention and medication. Higher cost components for PC patients were catering, room, nursing, social counseling, and nonmedical therapists. In sensitivity analyses, when we restricted PC exposure to three days from admission, total costs and average costs per day were significantly lower for PC.

CONCLUSION

Studies measuring the impact of PC on hospital costs should analyze various cost components beyond total costs to understand wanted and potentially unwanted cost-reducing effects. An international definition of a set of cost components, specific for cost-impact PC studies, may help avoid superficial and potentially dangerous cost discussions.

An evaluation of the cost-effectiveness of the different palliative care models available to cancer patients in Turkey

BACKGROUND

Three different models are commonly used to provide palliative care services to cancer patients in Turkey: comprehensive palliative care center (CPCC), hospital inpatient services (HIS) and home healthcare (HHC).

OBJECTIVES

The purpose of this study was to evaluate the cost-effectiveness of three alternative palliative care models for cancer patients.

METHODS

The study included a total of 160 patients diagnosed with cancer (CPCC:60, HIS:59, HHC:41). The patients' quality of life and their levels of satisfaction were used as the indicators of effectiveness, while direct and indirect costs incurred by service providers, patients and relatives were considered in estimating the costs of alternative models. The cost and effectiveness of the alternatives compared the "patient perspective" and "societal perspective" separately.

RESULTS

From a societal perspective, palliative care services provided the HIS model was found to be more cost-effective than the CPCC model. From a patient perspective, HHC was found to be more cost-effective compared to the other two models.

CONCLUSIONS

This study has the potential to provide substantial evidence to health managers and decision-makers with respect to health planning and the formulation of social security policies in Turkey.

Economics of Palliative Care for Hospitalized Adults With Serious Illness: A Meta-analysis

IMPORTANCE

Economics of care for adults with serious illness is a policy priority worldwide. Palliative care may lower costs for hospitalized adults, but the evidence has important limitations.

OBJECTIVE

To estimate the association of palliative care consultation (PCC) with direct hospital costs for adults with serious illness.

DATA SOURCES

Systematic searches of the Embase, PsycINFO, CENTRAL, PubMed, CINAHL, and EconLit databases were performed for English-language journal articles using keywords in the domains of palliative care (eg, palliative, terminal) and economics (eg, cost, utilization), with limiters for hospital and consultation. For Embase, PsycINFO, and CENTRAL, we searched without a time limitation. For PubMed, CINAHL, and EconLit, we searched for articles published after August 1, 2013. Data analysis was performed from April 8, 2017, to September 16, 2017.

STUDY SELECTION

Economic evaluations of interdisciplinary PCC for hospitalized adults with at least 1 of 7 illnesses (cancer; heart, liver, or kidney failure; chronic obstructive pulmonary disease; AIDS/HIV; or selected neurodegenerative conditions) in the hospital inpatient setting vs usual care only, controlling for a minimum list of confounders.

DATA EXTRACTION AND SYNTHESIS

Eight eligible studies were identified, all cohort studies, of which 6 provided sufficient information for inclusion. The study estimated the association of PCC within 3 days of admission with direct hospital costs for each sample and for subsamples defined by primary diagnoses and number of comorbidities at admission, controlling for confounding with an instrumental variable when available and otherwise propensity score weighting. Treatment effect estimates were pooled in the meta-analysis.

MAIN OUTCOMES AND MEASURES

Total direct hospital costs.

RESULTS

This study included 6 samples with a total 133 118 patients (range, 1020-82 273), of whom 93.2% were discharged alive (range, 89.0%-98.4%), 40.8% had a primary diagnosis of cancer (range, 15.7%-100.0%), and 3.6% received a PCC (range, 2.2%-22.3%). Mean Elixhauser index scores ranged from 2.2 to 3.5 among the studies. When patients were pooled irrespective of diagnosis, there was a statistically significant reduction in costs (-$3237; 95% CI, -$3581 to -$2893; P < .001). In the stratified analyses, there was a reduction in costs for the cancer (-$4251; 95% CI, -$4664 to -$3837; P < .001) and noncancer (-$2105; 95% CI, -$2698 to -$1511; P < .001) subsamples. The reduction in cost was greater in those with 4 or more comorbidities than for those with 2 or fewer.

CONCLUSIONS AND RELEVANCE

The estimated association of early hospital PCC with hospital costs may vary according to baseline clinical factors. Estimates may be larger for primary diagnosis of cancer and more comorbidities compared with primary diagnosis of noncancer and fewer comorbidities. Increasing palliative care capacity to meet national guidelines may reduce costs for hospitalized adults with serious and complex illnesses.

The effectiveness and cost‐effectiveness of inpatient specialist palliative care in acute hospitals for adults with advanced illness and their caregivers

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

Health Care Utilisation and Transitions between Health Care Settings in the Last 6 Months of Life in Switzerland

BACKGROUND

Many efforts are undertaken in Switzerland to enable older and/or chronically ill patients to stay home longer at the end-of-life. One of the consequences might be an increased need for hospitalisations at the end-of-life, which goes along with burdensome transitions for patients and higher health care costs for the society.

AIM

We aimed to examine the health care utilisation in the last six months of life, including transitions between health care settings, in a Swiss adult population.

METHODS

The study population consisted of 11'310 decedents of 2014 who were insured at the Helsana Group, the leading health insurance in Switzerland. Descriptive statistics were used to analyse the health care utilisation by age group, taking into account individual and regional factors. Zero-inflated Poisson regression model was used to predict the number of transitions.

RESULTS

Mean age was 78.1 in men and 83.8 in women. In the last six months of life, 94.7% of the decedents had at least one consultation; 61.6% were hospitalised at least once, with a mean length of stay of 28.3 days; and nursing home stays were seen in 47.4% of the decedents. Over the same time period, 64.5% were transferred at least once, and 12.9% experienced at least one burdensome transition. Main predictors for transitions were age, sex and chronic conditions. A high density of home care nurses was associated with a decrease, whereas a high density of ambulatory care physicians was associated with an increase in the number of transitions.

CONCLUSIONS

Health care utilisation was high in the last six months of life and a considerable number of decedents were being transferred. Advance care planning might prevent patients from numerous and particularly from burdensome transitions.

How much does care in palliative care wards cost in Poland?

INTRODUCTION

The main task of palliative care units is to provide a dignified life for people with advanced progressive chronic disease through appropriate symptom management, communication between medical specialists and the patient and his family, as well as the coordination of care. Many palliative care units struggle with low incomes from the National Health Fund (NHF), which causes serious economic problems. The aim of the study was to estimate of direct and administrative costs of care and the actual cost per patient per day in selected palliative care units and comparison of the results to the valuation of the NHF.

MATERIAL AND METHODS

The study of the costs of hospitalization of 175 patients was conducted prospectively in five palliative care units (PCUs). The costs directly associated with care were recorded on the specially prepared forms in each unit and also personnel and administrative costs provided by the accounting departments.

RESULTS

The total costs of analyzed units amounted to 209 002 EUR (898 712 PLN), while the payment for palliative care services from the NHF amounted to 126 010 EUR (541 844 PLN), which accounted for only 60% of the costs incurred by the units. The average cost per person per day of hospitalization, calculated according to the actual duration of hospitalization in the unit, was 83 EUR (357 PLN), and the average payment from the NHF was 52.8 EUR (227 PLN). Underpayment per person per day was approximately 29.2 EUR (125 PLN).

CONCLUSIONS

The study showed a significant difference between the actual cost of palliative care units and the level of refund from the NHF. Based on the analysis of costs, the application has been submitted to the NHF to change the reimbursement amount of palliative care services in 2013.

Evidence on the cost and cost-effectiveness of palliative care: a literature review

BACKGROUND

In the context of limited resources, evidence on costs and cost-effectiveness of alternative methods of delivering health-care services is increasingly important to facilitate appropriate resource allocation. Palliative care services have been expanding worldwide with the aim of improving the experience of patients with terminal illness at the end of life through better symptom control, coordination of care and improved communication between professionals and the patient and family.

AIM

To present results from a comprehensive literature review of available international evidence on the costs and cost-effectiveness of palliative care interventions in any setting (e.g. hospital-based, home-based and hospice care) over the period 2002-2011.

DESIGN

Key bibliographic and review databases were searched. Quality of retrieved papers was assessed against a set of 31 indicators developed for this review.

DATA SOURCES

PubMed, EURONHEED, the Applied Social Sciences Index and the Cochrane library of databases.

RESULTS

A total of 46 papers met the criteria for inclusion in the review, examining the cost and/or utilisation implications of a palliative care intervention with some form of comparator. The main focus of these studies was on direct costs with little focus on informal care or out-of-pocket costs. The overall quality of the studies is mixed, although a number of cohort studies do undertake multivariate regression analysis.

CONCLUSION

Despite wide variation in study type, characteristic and study quality, there are consistent patterns in the results. Palliative care is most frequently found to be less costly relative to comparator groups, and in most cases, the difference in cost is statistically significant.

Cost savings vary by length of stay for inpatients receiving palliative care consultation services

BACKGROUND

Cost savings associated with palliative care (PC) consultation have been demonstrated for total hospital costs and daily costs after PC involvement. This analysis adds another approach by examining costs stratified by hospital length of stay (LOS).

OBJECTIVE

To examine cost savings for patients who receive PC consultations during short, medium, and long hospitalizations.

METHODS

Data were analyzed for 1815 PC patients and 1790 comparison patients from two academic medical centers between 2005 and 2008, matched on discharge disposition, LOS category, and propensity for a PC consultation. We used generalized linear models and regression analysis to compare cost differences for LOS of 1 to 7 days (38% of consults), 8 to 30 days (48%), and >30 days (14%). Comparisons were done for all patients in both hospitals (n=3605) and by discharge disposition: survivors (n=2226) and decedents (n=1379); analyses were repeated for each hospital.

RESULTS

Significant savings per admission were associated with shorter LOS: For stays of 1 to 7 days, costs were lower for all PC patients by 13% ($2141), and for survivors by 19.1% ($2946). For stays of 8 to 30 days, costs were lower for all PC patients by 4.9% ($2870), and for survivors by 6% ($2487). Extrapolating the per admission cost across the PC patient groups with lower costs, these programs saved about $1.46 million for LOS under a week and about $2.5 million for LOS of 8 to 30 days. Patients with stays >30 days showed no differences in costs, perhaps due to preferences for more aggressive care for those who stay in the hospital more than a month.

CONCLUSION

Cost savings due to PC are realized for short and medium LOS but not stays >30 days. These findings suggest savings can be achieved by earlier involvement of palliative care, and support screening efforts to identify patients who can benefit from PC services early in an admission.