Costs and outcomes of advance care planning and end-of-life care for older adults with end-stage kidney disease: A person-centred decision analysis

Abstract

Background: Economic evaluations of advance care planning (ACP) in people with chronic kidney disease are scarce. However, past studies suggest ACP may reduce healthcare costs in other settings. We aimed to examine hospital costs and outcomes of a nurse-led ACP intervention compared with usual care in the last 12 months of life for older people with end-stage kidney disease managed with haemodialysis.

Methods: We simulated the natural history of decedents on dialysis, using hospital data, and modelled the effect of nurse-led ACP on end-of-life care. Outcomes were assessed in terms of patients' end-of-life treatment preferences being met or not, and costs included all hospital-based care. Model inputs were obtained from a prospective ACP cohort study among dialysis patients; renal registries and the published literature. Cost-effectiveness of ACP was assessed by calculating an incremental cost-effectiveness ratio (ICER), expressed in dollars per additional case of end-of-life preferences being met. Robustness of model results was tested through sensitivity analyses.

Results: The mean cost of ACP was AUD$519 per patient. The mean hospital costs of care in last 12 months of life were $100,579 for those who received ACP versus $87,282 for those who did not. The proportion of patients in the model who received end-of-life care according to their preferences was higher in the ACP group compared with usual care (68% vs. 24%). The incremental cost per additional case of end-of-life preferences being met was $28,421. The greatest influence on the cost-effectiveness of ACP was the probability of dying in hospital following dialysis withdrawal, and costs of acute care.

Conclusion: Our model suggests nurse-led ACP leads to receipt of patient preferences for end-of-life care, but at an increased cost.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1. Decision tree structure of advance care planning (ACP) in older people managed with dialysis.

The square symbol represents the choice of implementing ACP intervention versus no ACP intervention (usual care), the circle symbols represent the alternative chance events regarding cause of death and treatment preference being adhered to at end-of-life and the triangle symbol represents the absorbing (death) state. The hashtag symbols compliment the sum of the alternate branch probabilities to equate to 1.0.

Fig 2. Results of one-way sensitivity analyses for ACP versus usual care.

The horizontal black bars represent values for each model parameter that would lower the incremental cost-effectiveness ratio (ICER) of ACP; the grey bars represent values that would increase the ICER. For comparison, a line has been drawn at $50,000. Although this is an arbitrary threshold the Australian Government is more likely fund to fund health care interventions with an ICER of less than approximately $30,000AUD to $70,000AUD per Quality-Adjusted Life Year gained (depending on level of certainty). However, there is no known willingness to pay threshold for the outcome of this study.