The Effects on Costs of Palliative Care Teams in Hospitals

Transcription

1 The Effects on Costs of Palliative Care Teams in Hospitals Charles Normand Edward Kennedy Professor of Health Policy & Management 2017/07/26 Acknowledgements This presentation draws on findings from a number of studies, including the recent meta-analysis that is yet to be published. I am grateful to my collaborators on these: Peter May carried out most of the analysis in these studies and is first author on the main papers. Melissa M. Garrido, J. Brian Cassel, Egidio Del Fabbro, R. Sean Morrison assisted and advised on all aspects of the studies. Thanks also to Diane Meier, Amy Kelley and Melissa Aldridge. Financial support came from the Health Research Board in Ireland, The Atlantic Philanthropies (through CSI and KCL). 1

2 Outline of Presentation Assessing costs and benefits in palliative care The role of palliative care skills in expert decision making Palliative care consultation teams (PCCT) in US acute care settings Studies of PCCT Key findings in May et al 2015 and 2016 The reanalysis of older studies and meta-analysis Bringing healthcare into line with palliative care. Assessing costs and benefits in palliative care Ideally we would already have high quality evidence on the costs and benefits of palliative care interventions Challenges in assessing both costs and benefits If costs are lower and benefits no lower an interventions is clearly cost-effective Studies of PCCT in the US show better or no worse outcomes. 2

3 The role of palliative care skills in expert decision making Palliative care is inter alia about helping patients and families in achieving appropriate treatment and care trajectories Evidence shows that people have difficulty in accessing appropriate care and often receive too much or too little of services Expert decision support (aka PCCT interventions) changes treatment choices, can improve experiences, may extend life, may reduce cost. Palliative care consultation teams (PCCT) in US acute care settings PCCT is a major part of palliative care in the US, and the dominant form of hospital activity Most patients with life limiting illness do not have a consultation with a PCCT The important questions are who should have a PCCT consultation, how should the service be organized and does it need to expand. 3

4 Studies of PCCT Mainly observational trials hard to randomize in this setting Propensity score matching to control for all observed heterogeneity Studies did not demonstrate an effect on costs of PCCT interventions, but did generally show improved experiences One study (Temel) demonstrated a significant survival effect of interventions for lung cancer patients. Key findings in May et al 2015 and 2016 (1) The May et al analysis involved 2 new perspectives the timing of PCCT interventions and the degree of sickness (as described by Elixhauser co-morbidity) Not surprisingly early interventions make a significant difference to costs (within 6 days) and later ones do not, and very early ones (within 2 days of admission) have larger effects (20-35%). 4

5 Key findings in May et al 2015 and 2016 (2) The size of the effect is much larger for patients with complex multimorbidity Receipt of PCCT consultation within two days of admission was associated with 22 percent lower costs for patients with a comorbidity score of 2 3 and with 32 percent lower costs for those with a score of 4 or higher With early consultation savings come from both lower treatment intensity and shorter LOS Does the same apply in earlier studies? The reanalysis of older studies and meta-analysis Authors of existing published observational studies were approached to collaborate on a reanalysis and meta analysis of the evidence Of the 8 suitable studies 6 agreed to collaborate Reanalysis involved standardized approaches to propensity score matching, timing of intervention and multimorbidity Analysis was carried out separately for cancer and non cancer patients where feasible. 5

6 Results of Reanalysis and Meta-analysis 1 All diagnoses Study ATE ($) 95% CI Morrison, to Penrod, to 77 Morrison, to 638 McCarthy, to May, to Meta-analysis to Cancer ATE ($) 95% CI Morrison, to Penrod, to Morrison, to May, to McCarthy, to May, to Meta-analysis to

7 Non cancer ATE ($) 95% CI Morrison, to Penrod, to 5451 Morrison, to 5485 McCarthy, to May, to 1044 Meta-analysis to -280 Bringing healthcare into line with palliative care. Expert decision support (as in PCCT consultations) is associated with better experiences, lower costs and possibly longer survival This is particularly the case where patient needs are complex, and where there is multimorbidity This suggests that there is no case for NOT providing this kind of support, especially where needs are complex Many of the same issues probably apply in care of people with multimorbidity but who are not considered to have a need for palliative care. 7

8 Thank You for Your Attention 8