1. Cost-Effectiveness of Palliative Team Care For Patients Nearing End-Of-Life Society for Medical Decision Making 36 st Annual Meeting – Miami, Florida October 18 - 22, 2014

2. Contributors Ba’ Pham, PhDRobert Fowler, MD, MSc Peter Tanuseputro, MD, MScDouglas Manuel, MD, MSc Nancy Sikich, MScShamara Baidoobonso, PhD Petros Pechlivanoglou, PhDLes Levin, MD, MSc Murray Krahn, MD, MSc On behalf of the Health Quality Ontario Expert Panel on End-of-Life Care

3. 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

4. Objectives To evaluate the cost-effectiveness of in-home palliative team care for EOL patients and their family.

5. Palliative Team Care Timely identify palliative patients Need assessment Care coordination 24/7 access Symptom, social support interventions Psycho-spiritual care Bereavement care

6. Methods

7. Overview Model-based CEA Perspectives Healthcare payer’s (base case) Societal Time horizon: Last year of life Costs in 2014 Canadian dollar

8. 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

9. Model Structure Chronic conditions in LTC home Stable conditions at home Stable conditions at home with HOME CARE

10. 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

11. 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

12. 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

13. 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 Reviews Linked Health Admin. Micro-costing studies Health utility studies

14. Clinical Evidence Cochrane Systematic Review Gomes et al. 2013 Health Quality Ontario Systematic Review Sikich et al. 2014 Systematic Reviews Linked Health Admin. Micro-costing studies Health utility studies

15. Effects of Palliative Team Care # RCTsOutcomesOutcome Measures Rx versus Ctrl Estimate (95% CI) 4Patient’s QOLEffect size0.25 (0.05, 0.44) 6Hosp. admissionRisk ratio0.81 (0.67, 0.98) 5Hospital days  LOS -2.88 (-5.24, -0.52) Systematic Reviews Linked Health Admin. Micro-costing studies Health utility studies

16. Effects of Palliative Team Care # RCTsOutcomesOutcome Measures Rx versus Ctrl Estimate (95% CI) 4Patient’s QOLEffect size0.25 (0.05, 0.44) 6Hosp. admissionRisk ratio0.81 (0.67, 0.98) 5Hospital days  LOS -2.88 (-5.24, -0.52) 4ER visitRate ratio0.87 (0.70, 1.08) 1ICU admissionRate ratio0.78 (0.53, 1.17) 1ICU days  LOS -0.32 (0.83, 1.01) Systematic Reviews Linked Health Admin. Micro-costing studies Health utility studies

17. 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 billings Systematic Reviews Linked Health Admin. Micro-costing studies Health utility studies *Ontario Institute for Clinical Evaluative Sciences

18. Timing of Palliative Care

19. Transition Rates, e.g., ER Visits

20. Healthcare Resources Utilization ER: Emergency Room. LTC: Long-Term Care.

21. Cost of Palliative Team Care Micro-costing study (Klinger et al. 2011) Resource utilization and costs n=95 Ontario EOL patients Systematic Reviews Linked Health Admin. Micro-costing studies Health utility studies

22. Cost of Palliative Team Care $19 per patient per day Average service duration: 5 months Systematic Reviews Linked Health Admin. Micro-costing studies Health utility studies

23. Cost of Palliative Team Care

24. 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 Reviews Linked Health Admin. Micro-costing studies Health utility studies

25. Out-of-Pocket Expenses and Unpaid Care Costs

26. Health Utility Estimates Selected Studies Palliative cancer patients Patients at home (± home care), long-term care Patients in ER, hospital and ICU Systematic Reviews Linked Health Admin. Micro-costing studies Health utility studies

27. Quality of Life - Patients Palliative 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

28. Health Utility – Family A Selected Study Collateral effects on family and caregivers Spillover effects are measurable (Prosser et al. 2014) Standard gamble technique Systematic Reviews Linked Health Admin. Micro-costing studies Health utility studies Estimated Spillover Disutility: ~0.1

29. Results

30. Effectiveness Estimates * In-Home Palliative Team Care Usual CarePTCIncr. Dying at home46%51%5% Days at home3373436

31. Base Case Analysis Notes: PTC In-Home Palliative Team Care. NMB: Net Monetary Benefit at $50,000 per QALY Usual CarePTCIncrementalIncr. NMB Cost 49,96446,788-3,175 4,662 QALY 0.590.620.03

32. One-Way Sensitivity Analysis

33. Daily Cost of Palliative Team Care Threshold : $42 Base: $19 Cost per patient: $4,423 Average service duration: 8 months

34. Probabilistic Sensitivity Analysis Note: PSA with n= 20,000

35. Unpaid Care Cost Borne by Family

36. Quality of Life of Patients and Spillover Effect on Family

37. 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.

38. Limitations Impact on time to death was not considered QALY framework may not be appropriate for EOL care

39. Thank you! Comments and Questions?