Cost effectiveness analysis of advance care planning in Australia

Transcription

1 Cost effectiveness analysis of advance care planning in Australia Dr. Kim-Huong Nguyen Co-authors: Tracy Comans, Marcus Sellars, and the CDPC team

2 What is an advance care plan? ACP is a process whereby a patient, in consultation with health care providers, family members and important others, makes decisions about his or her future health care, should he or she becomes incapable of participating in medical treatment decision (Detering et al 2010) Process not just the end product (e.g. legal document such as advance directive) Decision about future health care should he/she becomes incapable of decision making.

3 ACP for patients with dementia ACP is essential for everyone but even more important when individuals are confronting an illness such as dementia, knowing that the progression of the disease ultimately result in losing ability to make the decision while confronting decision related to the end of life In Australia, studies in dementia and other palliative care populations found that discussion of end of life issues may often not take place or start too late

4 Why ACP? Benefits of the ACP process include patient empowerment, autonomy, and decreased resource utilisation Patient participation in making care decision People deserve a good end of life: a good death gives people dignity, choice and support to address their physical, personal, social and spiritual needs There are evidence that it leads to better outcomes for both patients and families

5 Why ACP? ACP also reduces health care resources used (thus cost) two systematic reviews: Klingler et al. showed that facilitated ACP had the potential to reduce net costs of care Dixon et al. found associations between ACP and healthcare savings for people living with dementia in the community, and people living in areas with high EOL care spending Both of them did not systematically identify costs and outcomes, and the potential trade-off between these.

6 Objectives Estimate the cost effectiveness of ACP in the Australia context Inform policy makers on the possibility of having an ACP program (including potential design and implementation of an ACP program?)

7 PICO Population: Australian population aged 65+ Intervention: primary care intervention to provide ACP Comparator: existing situation in Australia where there is no system-wide approach to provide ACP Outcome: costs and QALYs, cost effectiveness

8 The model Perspective: Australian health system Duration: Life time Cycle length: one year Health states: No dementia, Mild, Moderate, Severe and Dead At any point in time, an individual can fall very ill and move to end-of-life care before dead Differences between the two scenarios all come down to end-of-life care ACP program is expected to increase the ACP completion and compliance rates, improve quality of life, and decrease unnecessary hospitalisation and resuscitation.

9 Model structure

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11 Data: transition probabilities Transition probabilities: Developing dementia: meta-regression analysis was used to obtain prevalence and incidence rates Age dependent Dementia progression: based on Neumann et al 2001 s estimation for Alzheimer's disease progression (80% of dementia is AD) Mortality risk Age dependent

12 Data: transition probabilities Having an ACP: Current situation scenario: Detering et al 2010 With ACP program scenario: unknown to be tested ACP compliance (end-of-life wishes being respected): Detering et al Without ACP: With ACP: Hospitalisation (end of life): Hunt at al (SA study) Without ACP: 0.67 With ACP: 0.15

13 Data: resources and costs ACP program: GP-based: 2 initial visit plus 4 more visits for discussion and finalisation + extra 2 visits for review/revisions etc. Initial visit ~ MBS item 141 (treatment plan and management for the elderly) Follow up visit ~ MBS item 732 (follow up for treatment plan and management for the elderly) ACP trained nurse/social workers: a package with 4-5 standard visit to discuss and complete an ACP + additional visit for review/revision Set-up cost for the program (recruitment, training, liaison with GP for get referral, recurrent salary and expenditure)

14 Data: resources and costs Hospitalisation at end of life Age dependent Regression analysis using data from Kardamanidis et al., 2007 Hospital inpatient costs for older people in NSW in the last year of life 70,384 people aged 65 years and above Non-hospitalisation at end of life No information! Assume ~60% of the hospitalisation cost (likely to be less than 60%) sources Brumley et al, Shnoor et al, Caplan et al

15 Data: utilities Utility weights for different dementia health state, and end of life Various sources in the literature not fully agree with each other! Meta-regression analysis to allow for age dependent: The older the lower quality of life in general Allow for negative utility (worse than dead) at end of life for very old people Can allow for negative utility if patients wish (e.g., ACP) is not respected Base case hasn t included negative utility yet.

16 Preliminary results Both scenarios produce same QALY The main difference is hospitalisation costs QALY difference due to negative utility hasn t been included if included, then with ACP program generates higher QALYs With ACP program scenario is slightly cheaper 16,371 vs. 16,443: the cost saving was generated from a lower rate of hospital-based end-of-life care for patients who had an ACP If starting age is 75+ then with ACP program is slightly more expensive Introduce earlier better than later?

17 Policy discussion Uptake rate for ACP program: Delicate balance between high operation cost of the program vs. savings generated from preventing unnecessary hospitalisation Break-even around 62% - but depending on Hospitalisation rate We cannot (and should not???) influence this as it is the patient s reference ACP compliance rate We can influence this by making sure that an ACP, once completed by the patients, is known by the family, and health system (GP, specialist, hospitals etc.)

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21 Policy messages Uptake rate GP referral to trained nurses/social workers Community-based information dissemination Compliance Family, caregiver, clinician involvement System-wide acceptance of ACP Good alternative care option (to hospital) Good palliative care or hospice so people (at home) can be admitted when in need instead of hospital More resources in residential care so they can deal with severe cases more effectively