Does end of life care present specific challenges in economic evaluation?

Abstract:
Background: Whilst decision analytical models are becoming common in assessing the cost effectiveness of health care interventions, evaluating the cost effectiveness of treatments for end of life care is thought to present specific challenges.

Purpose: This paper explores the challenges faced when conducting an economic analysis using decision analytical modelling at end of life. We used advanced cancer as a proxy for end of life care. 

Methods: A systematic review focusing on the search terms: advanced or terminal illness, cancer, and cost or economic studies. Studies were included where they reported economic evaluations using decision analytical models, included patients with advanced cancer and were published in English. Data was extracted on the health system context, model type, model time horizon, and model outcomes.

Data Synthesis: Twenty eight papers were eligible for inclusion. Nine models used lifetime horizons, with the remainder using various durations.   Model outcomes varied; most used quality of life (QOL), but some used survival, and one estimated the likelihood of effective pain management.

Conclusions: Overall many of the challenges faced in the models in this review are common to all decision analytical modelling in cost effectiveness analysis; the lack of head to head clinical trials; and, where clinical data is available, the protocol driven costs and outcomes which may not reflect usual practice. However, the over-riding challenge identified here relates to how outcomes are measured. Whilst survival, progression free survival or life years gained provide a quantitative measure of outcome they do not reflect quality of life. For those models that did incorporate quality of life this was primarily valued by health care professionals. Recent policy decisions on end of life care in England have focused on the weight given to QALYs in terms of proximity to death but there is still an underlying issue of how utility at end of life is valued and whether a special case could or should be made for evaluating end of life care differently than other interventions.