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Original Investigation
June 2018

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

Author Affiliations
  • 1Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
  • 2Cicely Saunders Institute of Palliative Care, Policy, and Rehabilitation, King’s College London, London, England
  • 3Massey Cancer Center, Virginia Commonwealth University, Richmond
  • 4Baylor Scott & White Health, Dallas, Texas
  • 5Brown University, Providence, Rhode Island
  • 6James J. Peters Veterans Affairs Medical Center, New York, New York
  • 7Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
JAMA Intern Med. 2018;178(6):820-829. doi:10.1001/jamainternmed.2018.0750
Key Points

Question  What is the estimated association of palliative care consultation within 3 days of admission with direct hospital costs for adults with serious illness?

Findings  In this meta-analysis of 6 studies, hospital costs were lower for patients seen by a palliative care consultation team than for patients who did not receive this care. The estimated association was greater for those with a primary diagnosis of cancer and those with more comorbidities compared with those with a noncancer diagnosis and those with fewer comorbidities.

Meaning  The estimated association of palliative care consultation with hospital costs varies according to baseline clinical factors; prioritizing current staff to patients with a high illness burden and increasing capacity may reduce hospital costs for a population with high policy importance.

Abstract

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.

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