We hope you enjoyed the EAPC 12th World Research Congress! All congress content is available online for delegates until 30th September 2022. There were many highlights from #EAPC2022 but we particularly enjoyed the award presentations, which included the Journal of Palliative Medicine’s Paper of the Year award. The winners were Claudio Cartoni and colleagues for their paper about whether early, home based palliative care can be cost effective.
People with blood cancer have complex and specific needs,often requiring care from a range of different healthcare professionals.This can be impractical and overwhelming for both people undergoing treatment and their loved ones, representing a considerable psychological and emotional burden. Frequent hospital visits for different kinds of outpatient treatment can be highly disruptive to a person’s life due to factors such as long travel times, the cost of travel and being isolated from family. Therefore, a specific programme of home-based provision of early palliative care was developed in order to respond to the care problems suffered by some categories of frail patients with hematological diseases. The programme, run by a specialist hematological team with skills in basic palliative care, aims to improve the quality of life of patients and their carers, and to reduce the number and costs of inappropriate hospitalisation. Its key aspects include controlling symptoms, psychosocial care, a personalised management plan capable of maximising patients’ quality of life and the provision of co-ordinated services, especially at home but also in the hospital and in day care units. This type of assistance is provided by multidisciplinary teams of physicians, nurses, psychologists, social workers and a physiotherapist. Direct contact with the hospital blood bank assures the availability of blood products. An infectious disease specialist, a heart specialist, a neurologist and an orthopedic of the hospital are also available for consultation. The home service initially assisted patients with chronic or terminal illnesses but it was later also employed for the supportive care of patients discharged by the hospital wards after chemotherapy or hematopoietic stem cell transplantation programmes.
Although the main reason for this programme is to assist patients and their families, the financial constraints conditioning the national health systems required an accurate evaluation of the economic advantage of this home-based solution compared with the consolidated services offered hospital-based setting. Therefore, we designed a real-life, non-randomised comparative study in order to assess costs, use of resources and clinical outcomes between an early palliative home care programme versus standard hospital care for patients with an advanced illness (treated with life-prolonging therapies) or those with terminal phase, who were receiving only supportive care. The allocation of patients to either home or hospital care was based on pragmatic considerations such as caregiver availability, distance from the hospital and patient preference. Our analysis focused on resources use, events requiring blood unit transfusions or parenteral therapy, patient-reported symptom burden, mean weekly cost of care, cost-minimisation difference and incremental cost-effectiveness ratio (ICER).
Of 119 patients enrolled in the study, 59 patients cared at home were more debilitated and had a shorter survival than the 60 in hospital group (p = 0.001). Nevertheless, symptom burden was similar in both groups. At home the mean weekly number of transfusions (1.45) was lower than that at hospital (2.77). Higher rate of infections occurred at hospital (54%) versus home (21%; <0.001). Mean weekly cost of care for hospitalisation was significantly higher in a 3:1 ratio versus home care. Compared with hospital, home based assistance produced a weekly saving of e 2314.9€ for the health provider, with a charge of 85.9€ for the family. It was cost-effective by an ICER of -7013.9€ of prevented days of care for avoided infections. Patient-reported symptom burden did not show a significant difference between home and hospital care with regard to change over time, suggesting that symptom control at home was not worse than the one that could be achieved in the hospital. This is an important finding considering that patients in the home care group consisted of more debilitated and older patients than those represented in the hospital care group.
Our study has several limitations, including the limited number of patients enrolled, the non-randomised study design and the lack of details about colonisation and primary antimicrobial treatment undertaken. Also, the study was conducted in two centres where an institutional home care programme was available and active for several years with dedicated trained personnel and, therefore, findings cannot be generalised to those hospitals for which such support is not available.
In conclusion, this study findings suggest that costs of early palliative home care for patients with hematologic malignancies are lower than standard hospital care costs. Home-based assistance may also be cost-effective by reducing the number of days to treat infections in immunocompromised patients.
Charles F. von Gunten, Editor of the Journal of Palliative Medicine, commented on the reason for choosing this paper as their Paper of the Year and explains more about the Journal:
‘In addition to excellent study design and analysis, the subject is a ‘leading edge’ issue globally as the innovation of combining palliative care with standard treatments for cancer now reaches hematological malignancies. This is not unlike other areas of cancer research where independently proven approaches are combined to achieve better outcomes than either approach alone.’
‘The Journal of Palliative Medicine is a global journal with editorial board membership and manuscripts from around the world. The Time-to-First Decision averages only nineteen days and represents our commitment to provide authors with prompt decisions and not have their manuscripts languish in decision queues. We are not just an American journal – the journal enjoys exceptional global visibility. In 2021, there were 1,240,961 full-text downloads and 1,265,512 abstract-only downloads for a total of 2.5 million downloads. Outside the United States, Canada, the United Kingdom, Australia, China, Germany, India, Japan, Brazil, and Singapore are the countries that currently most use the journal. The Journal of Palliative Medicine looks and feels different from other scientific journals serving the field because it has the clinician in mind. In contrast with scientific journals for whom the target is academic researchers, when reviewing submissions, we ask: ‘What will help the clinician who is frequently working in our field to understand what is ‘new’ and what can influence practice?’’
Links and resources
- Cartoni C, Breccia, M, Giesinger JM, et al ‘Early Palliative Home Care versus Hospital Care for Patients with Hematologic Malignancies: A Cost-Effectiveness Study’. Journal of Palliative Medicine,Volume 24, Number 6, 2021. Read this paper here.
- Click here to find out more about the Journal of Palliative Medicine.
About the author
Claudio Cartoni is a Hematologist and Medical Director of Policlinico Umberto I, Rome and a Professor at the department of Department of Cellular Biotechnology and Hematology, Sapienza University of Rome.
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Thank you highlighting the very important topic of reducing costs for the health system by providing early palliative care! This is a topic of high importance to all of our countries since we are all strugling with limited financial ressources. It is a topic were much more data is needed, as well.
Again thank you very much!