However, the argument between ethical and economic considerations is a false one. Health economists share with other researchers the same objective: ensuring that the most useful and effective care is made available. And the economic perspective is essential if that objective is to be met.
The improvement and expansion of care for people with serious illness is a public health priority around the world. High levels of unmet need are well documented; projections of future need are daunting. Sufficient provision of humane, expert treatment for people living and dying with serious illness and functional impairment requires large-scale expansion in training and practice.
Such expansion will not occur without clear scientific evidence, including economic evaluation. Healthcare funders in the governmental and charitable sectors face competing demands for limited budgets, never more so than after years of severe recession. Those budgets must be allocated where they will do the most good. While decisions in the clinical setting should never be based on cost considerations, in a managerial context resources cannot be allocated without them.
If palliative care is to sustain its remarkable rate of growth over the last 25 years, the evidence base on its impact must continue to grow as well.
Last week the Journal of Clinical Oncology (JCO) published new research, for which I am the lead author, with new and important evidence on economic impact. Using a study of 969 patients admitted to five United States hospitals with advanced cancer, we report that an early specialist palliative care consultation following hospital admission significantly reduces the cost of care for patients admitted with advanced cancer.
We also found that the earlier the intervention is delivered in the hospitalisation, the larger the cost-saving effect, and that the magnitude of cost-savings from early palliative care is larger than previously understood. This is the first paper to demonstrate the association between intervention timing and economic impact.
The savings accrue through both reduced length and intensity of hospital stay following goals of care discussions with palliative care clinicians who identify treatment choices consistent with patient preferences. For many people with serious illness, enhanced quality of life and the opportunity to return home is favoured over remaining in hospital receiving burdensome interventions with a low likelihood of success.
Previous studies of this and similar interventions report improved clinical outcomes, including pain and symptom burden and anxiety, as well as improved satisfaction among patients and their families. In some cases evaluations of early palliative care interventions also report improved survival.
Taken together, the published evidence on specialist palliative care interventions shows a consistent and growing pattern of similar or better outcomes for lower costs.
A major challenge in continuing to grow the evidence base is the inherent diversity and complexity of palliative care.
Hospital-based specialist interventions represent one domain of many in the field. In particular, care for people with serious illness in an era of population ageing will not be focused solely on institutional settings. Where possible, most patients prefer to receive care at home rather than hospice or hospital, whose inpatient costs account for large proportions of healthcare expenditure. And many patients who have serious illness but not specialist palliative care needs will require access to appropriate care in an appropriate setting.
As the emphasis of provision increasingly becomes about different settings and levels of specialism, research and evidence on new programmes is essential. There is not a single question – ‘is palliative care cost-effective?’ – since palliative care is many things to many people. Rather, questions of cost-effectiveness must be addressed for multiple interventions in different settings and populations.
Our JCO research emerged from an ongoing collaboration between Trinity College Dublin and Mount Sinai School of Medicine in New York, and we will now look to apply our findings in the Irish context.
We cannot be certain that results observed in the United States will be transferable, due to obvious differences between the two countries and their health systems. Nonetheless we can hypothesise that patient-centred interventions may offer the same potential for improving the care of people with serious illness while limiting cost growth.
It is well known that there are excellent palliative care services long established across Ireland, but also that there is a high level of unmet need in some parts of the state with limited palliative care access. One important impediment to growing access has been a lack of credible economic evaluation of existing provision. The case for expanding current programmes and implementing new ones, particularly during a period of health budget cuts, has been weakened by this evidence gap.
Research activity to fill the gap is increasingly visible. Colleagues at Trinity College Dublin and the Economic and Social Research Institute are soon to publish a report, “Economic Evaluation of Palliative Care in Ireland”, with important insights on the economic impact of services in three regions with varying levels of local services. Studies are also under way evaluating innovative new programmes that follow international trends towards volunteer- and community-led provision for people with less complex needs.
The need for these studies and more is urgent given the scale of challenges posed. The more economic evidence we can gather on palliative care, the more likely it is that future services will be equipped to address what is truly important.
Peter May is HRB Economics of Cancer Fellow at the Centre for Health Policy and Management at Trinity College Dublin, and a Visiting Health Economics Research Fellow at the Icahn School of Medicine at Mount Sinai in New York.