Research Article: 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

Date Published: May 31, 2019

Publisher: Public Library of Science

Author(s): Marcus Sellars, Josephine M. Clayton, Karen M. Detering, Allison Tong, David Power, Rachael L. Morton, Wisit Cheungpasitporn.


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.

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.

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.

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

Partial Text

Advance care planning (ACP) supports people to consider and communicate their future treatment preferences in the context of their own goals and values. For people with chronic kidney disease (CKD), ACP can alleviate depression and indecision regarding the burden of dialysis, uncertainties about the future and inevitable death [1], and broaden the focus from dialysis and maintaining physical health [2, 3] to identifying and addressing goals that patients have for their remaining lives [4, 5]. ACP can also assist caregivers to overcome decisional and personal conflict and to act in accordance with patients’ end-of-life preferences [1, 6]. Yet ACP is estimated to occur with only 6–49% [7–11] of people with CKD internationally.

Study reporting is based on the consolidated health economic evaluation reporting standards (CHEERS) statement and the completed checklist is reported in Supporting Information File S1 Appendix [17].

The cost of implementing the ACP intervention was on average $519 per patient. The average cost per patient for the ACP group was $100,579 (SD = 17,356) and the proportion of patients receiving end-of-life care according to preferences was 68% (SD = 48). In the no ACP group, the average cost per patient was $87,282 (SD = 19,078) and the proportion of patients having preferences met was 24% (SD = 43). The average hospital costs incurred by patients in the last 12 months of life was higher for patients who withdrew from dialysis versus those who died from other causes ($110,696 vs. $71,737, Table 2).

In our decision analysis model, ACP was more effective in facilitating adherence to treatment preferences but was more expensive than usual care for older people with ESKD managed on dialysis. Patients in the ACP group were almost three times more likely to receive end-of-life care in accordance with their preferences compared to usual care and the mean additional cost was $28,421 per patient in the last 12 months of life. The one-way sensitivity analyses showed that costs of care in the last 12 months of life (preceding withdrawal of dialysis or preceding death from other causes) and the probability of patients in the ACP group dying from withdrawal of dialysis had the greatest influence on the cost-effectiveness result. By comparison, the cost of the ACP intervention had the least influence on cost-effectiveness in the model.




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