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Economic (gross cost) analysis of systematically implementing a programme of advance care planning in three Irish nursing homes

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Abstract

Background Although advance care planning (ACP) and the use of advanced care directives (ACD) and end-of-life care plans are associated with a reduction in inappropriate hospitalisation, there is little evidence supporting the economic benefits of such programmes. We assessed the economic impact (gross savings) of the Let Me Decide (LMD) ACP programme in Ireland, specifically the impact on hospitalisations, bed days and location of resident deaths, before and after systematic implementation of the LMD-ACP combined with a palliative care education programme. Methods The LMD-ACP was introduced into three long-term care (LTC) facilities in Southern Ireland and outcomes were compared pre and post implementation. In addition, 90 staff were trained in a palliative care educational programme. Economic analysis including probabilistic sensitivity analysis was performed. Results The uptake of an ACD or end-of-life care post-implementation rose from 25 to 76 %. Post implementation, there were statistically significant decreases in hospitalisation rates from baseline (hospitalisation incidents declined from 27.8 to 14.6 %, z = 3.96, p < 0.001; inpatient hospital days reduced from 0.54 to 0.36 %, z = 8.85, p < 0.001). The percentage of hospital deaths also decreased from 22.9 to 8.4 %, z = 3.22, p = 0.001. However, length of stay (LOS) increased marginally (7–9 days). Economic analysis suggested a cost-reduction related to reduced hospitalisations ranging between €10 and €17.8 million/annum and reduction in ambulance transfers, estimated at €0.4 million/annum if these results were extrapolated nationally. When unit costs and LOS estimates were varied in scenario analyses, the expected cost reduction owing to reduced hospitalisations, ranged from €17.7 to €42.4 million nationally. Conclusions Implementation of the LMD-ACP (ACD/end-of-life care plans combined with palliative care education) programme resulted in reduced rates of hospitalisation. Despite an increase in LOS, likely reflecting more complex care needs of admitted residents, gross costs were reduced and scenario analysis projected large annual savings if these results were extrapolated to the wider LTC population in Ireland.
O’Sullivan et al. BMC Res Notes (2016) 9:237
DOI 10.1186/s13104-016-2048-9
RESEARCH ARTICLE
Economic (gross cost) analysis
ofsystematically implementing a programme
ofadvance care planning inthree
Irish nursing homes
Ronan O’Sullivan1, Aileen Murphy2, Rónán O’Caoimh1,3,4*, Nicola Cornally1,5, Anton Svendrovski6, Brian Daly7,
Carol Fizgerald1,4, Cillian Twomey7, Ciara McGlade1 and D. William Molloy1,4
Abstract
Background: Although advance care planning (ACP) and the use of advanced care directives (ACD) and end-of-life
care plans are associated with a reduction in inappropriate hospitalisation, there is little evidence supporting the
economic benefits of such programmes. We assessed the economic impact (gross savings) of the Let Me Decide
(LMD) ACP programme in Ireland, specifically the impact on hospitalisations, bed days and location of resident deaths,
before and after systematic implementation of the LMD-ACP combined with a palliative care education programme.
Methods: The LMD-ACP was introduced into three long-term care (LTC) facilities in Southern Ireland and outcomes
were compared pre and post implementation. In addition, 90 staff were trained in a palliative care educational pro-
gramme. Economic analysis including probabilistic sensitivity analysis was performed.
Results: The uptake of an ACD or end-of-life care post-implementation rose from 25 to 76 %. Post implementation,
there were statistically significant decreases in hospitalisation rates from baseline (hospitalisation incidents declined
from 27.8 to 14.6 %, z = 3.96, p < 0.001; inpatient hospital days reduced from 0.54 to 0.36 %, z = 8.85, p < 0.001). The
percentage of hospital deaths also decreased from 22.9 to 8.4 %, z = 3.22, p = 0.001. However, length of stay (LOS)
increased marginally (7–9 days). Economic analysis suggested a cost-reduction related to reduced hospitalisations
ranging between 10 and 17.8 million/annum and reduction in ambulance transfers, estimated at 0.4 million/
annum if these results were extrapolated nationally. When unit costs and LOS estimates were varied in scenario analy-
ses, the expected cost reduction owing to reduced hospitalisations, ranged from 17.7 to 42.4 million nationally.
Conclusions: Implementation of the LMD-ACP (ACD/end-of-life care plans combined with palliative care education)
programme resulted in reduced rates of hospitalisation. Despite an increase in LOS, likely reflecting more complex
care needs of admitted residents, gross costs were reduced and scenario analysis projected large annual savings if
these results were extrapolated to the wider LTC population in Ireland.
Keywords: Advanced care planning, Advanced care directives, Economic analysis
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Open Access
BMC Research Notes
*Correspondence: rocaoimh@hotmail.com
3 Health Research Board, Clinical Research Facility Galway, National
University of Ireland, Galway, Geata an Eolais, University Road,
Galway City, Ireland
Full list of author information is available at the end of the article
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Page 2 of 10
O’Sullivan et al. BMC Res Notes (2016) 9:237
Background
By 2050, the Irish population aged over 65years will dou-
ble to 1.4 million. Currently, 5% reside in long term care
(LTC) but while the proportion may remain unchanged,
the total number of residents is expected to rise [1].
Increases will be even greater in those over 85years, of
whom 21% currently reside in LTC [2]. Over the next
10 years, approximately 1000 extra LTC beds will be
required, each year, to accommodate the rising need for
LTC [3]. Increasing numbers of people will die in LTC
[46] making it essential that LTC facilities provide the
highest quality end-of-life care.
Patient involvement in medical decision-making is
encouraged and advance care planning (ACP) allows
people to consider their wishes for end-of life care and to
state their wishes should they become incapable of com-
municating them later. ACP is defined as a continuous
communication and decision-making process between
patients, families and healthcare professionals, address-
ing issues relating to end-of-life care prior to the patient
requiring such care. ACP may result in the development
of a written document called an advance care directive
(ACD), a frequent but facultative result of the ACP pro-
cess, or an end-of-life care plan. An ACD is a record of
an informed decision, valid only if a competent individual
makes it voluntarily and is used or acted upon only if the
person becomes incompetent to make medical decisions.
Depending on the jurisdiction, an ACD can be legally
binding. An end-of-life care plan is created between indi-
viduals who lack capacity, their family, and healthcare
professionals to plan for future healthcare decisions. It is
not legally binding, rather a road map to guide the deci-
sion making process. While a resident who lacks deci-
sion-making capacity is ineligible to complete an ACD,
any expressed views in relation to end-of-life care can be
documented in this end-of-life care plan. ACP includ-
ing the creation of either an ACD or end-of-life care plan
offers a unique opportunity to optimise care, promote
autonomy, empower patients and maximise resource use
[7]. It promotes collaborative care, reduces heath ine-
qualities by increasing access to palliative care, improves
satisfaction with end-of-life care and facilitates choice of
place of death [811].
Ireland is on the cusp of major changes in relation to
advance decision-making. e Law Reform Commission
made strong recommendations to give ACDs a legal basis
and the new Assisted Decision-Making (capacity) Bill
2013, once enacted, will provide a statutory framework
for ACDs. Before ACDs become widely available in Ire-
land, we need to understand the clinical value and impact
they will have, including their cost effectiveness and fea-
sibility. ere is poor evidence to support the use of ACP
interventions including ACDs and end-of-life care plans
for older people, particularly those with cognitive impair-
ment [1214]. e paucity of supporting evidence is due
to a lack of quasi-experimental, controlled before-after or
randomised controlled trials (RCT) particularly in LTC
[7]. Most research in this area is descriptive or qualitative
often focusing on ACD or end-of-life care plan comple-
tion rates, rather than on their effects on quality of end-
of-life care or on their economic impact [1517].
Let Me Decide (LMD) is an established ACP pro-
gramme, originally developed in Canada [7] (LMD-ACP)
and is a selected good practice initiative within the Col-
laboration on Ageing (COLLAGE), Ireland’s 3 Star Ref-
erence Site for the European Innovation Partnership on
Active and Healthy Ageing (http://www.collage-ireland.
eu/initiatives/specific-action-group-members/let-me-
decide/) [18, 19]. LMD was systematically implemented
in pilot studies [2022] and in a RCT in LTC in Canada
[8]. e majority of residents completing directives
chose to remain in the LTC facility and receive appro-
priate palliative end-of-life care [8]. Similar results were
found in the United States with significant cost savings in
their final week of life [23]. Higher costs were associated
with worse quality of death [23]. In Australia, 21 nurs-
ing homes and two hospitals using LMD were compared
to a geographically separate hospital and thirteen nurs-
ing homes. During a 3-year follow up period there was
a significant reduction in emergency ambulance calls in
the intervention homes (p< 0.0019) and a 25% reduc-
tion in hospital bed occupancy by intervention home
residents compared to control homes (relative risk 0.74;
p<0.0001) [9].
e currentstudy evaluated the feasibility of systemati-
cally implementing the LMD-ACP programme in three
Irish LTC facilities together with a palliative care work-
shop. e introduction of this programme into these
pilot LTC settings in Ireland has been mostly a positive
experience and the programme was well received [24].
is paper describes the economic gross cost analysis of a
pilot study, assessing the impact on hospitalisations, loca-
tion of residents’ deaths and number of days the nursing
home residents spent in acute hospital care, before and
after systematic implementation.
Methods
ree LTC facilities were recruited from the south of
Ireland. ese included two private and one publically
funded (community nursing unit) nursing homes, total-
ing 290 beds at baseline. All residents, aged 65years, in
participating unitswere eligible for inclusion in the pro-
gramme. Residents were recruited throughout the study
period. New residents were included in the analysis such
that bed occupancy was maximized throughout follow-
up. is number grew from baseline to the beginning
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Page 3 of 10
O’Sullivan et al. BMC Res Notes (2016) 9:237
of the post-implementation phase as the bed capacity of
two of the units increased during this period. Beds occu-
pied by participants excluded from the study (i.e. those
residents <65 years) did not contribute to the analysis
of outcomes, which were calculated as average annual
event rates per available occupied bed across the three
units. Statistical and economic analysis is expanded upon
below. e study adhered to the tenets of the Declara-
tion of Helsinki (1975). e study was approved by the
Clinical Research Ethics Committee of the Cork Teach-
ing Hospitals and residents provided informed con-
sent where possible. Assent was obtained for those who
lacked capacity.
The advance care planning andpalliative care education
intervention
Nursing staff from participating homes completed two
half-day workshops on the LMD-ACP programme focus-
ing on the ethical, legal and practical considerations of
ACP with residents and their families in LTC. A sepa-
rate education programme in palliative care was deliv-
ered over another two half-days. e first palliative care
half-day, attended by nurses and healthcare assistants,
focused on the palliative care approach, communication
at end-of-life and issues relating to grief and bereave-
ment. e second half-day, delivered to nursing staff only,
focused on symptom assessment and management. is
education aimed to provide staff with the skills to deliver
holistic, patient-centered care, using the principals of
palliative care and the ability to recognise when timely
referral to specialist palliative care services would benefit
dying residents, to ensure they received high quality end-
of-life care.
Each study home was given a detailed implementa-
tion manual that included a policy on completing ACDs/
ACPs, decision aids for engaging residents, documen-
tation templates, structured forms and educational
resources for residents and families. Live ACP demon-
strations with a sample of residents and families in front
of small groups of nursing staff in all three study sites
were given. Senior nursing staff were offered support
in monthly feedback meetings to discuss issues aris-
ing during the implementation process. Residents were
approached in turn, on the unit for existing residents or
on admission to the unit for new residents, during the set-
up phase. Residents and families who expressed an inter-
est were provided with information about the LMD-ACP
programme by senior nurses. In addition, one-off, even-
ing and weekend, information sessions for families and
residents were delivered in the homes by senior members
of the research team. After, residents and families were
asked if they wished to participate, resident’s capacity to
complete the LMD-ACD was then assessed [25]. Each
competent resident who voluntarily decided to engage
in the LMD-ACP process was given a verbal and written
explanation of the study. Residents were asked to sign a
consent form and were assured that any information col-
lected would be treated as strictly confidential. ey were
also informed that they were free to withdraw their con-
sent to participate at any time, that they were under no
obligation to complete an ACD, that their decision to
engage in the ACP process would not affect the quality
or amount of healthcare that they would receive, and that
there would be no risks involved by their participation in
the study. ose residents who completed an ACD were
informed that they could change or withdraw their ACD
at any time they wished. Likewise, families of incompetent
residents who voluntarily decided to engage in the LMD-
ACP process were invited to complete an end-of-life care
plan. ey were then also asked to sign consent and were
given the same assurances as competent residents. An
opportunity for the resident to provide a personal state-
ment is fosteredand included in the documentation.
Implementation of‘Let Me Decide’
e LMD-ACP implementation is divided into four steps
[26]:
1. e first step in the LMD-ACP process screens
cognition, using the Standardised Mini-Mental
State Examination (SMMSE) [27]. is determines
whether a resident is likely to have sufficient capac-
ity to engage and understand the ACP process. Resi-
dents who were deemed suitable (SMMSE score >10)
were offered the opportunity to engage in the LMD-
ACP process.
2. Education is provided with trained senior nurses
informing residents and family members individu-
ally that a new advance directive program is being
implemented and that they have an opportunity to be
educated about directives and to complete one. e
nurses explain the five sections of the LMD directive,
the terminology such as the type of care they would
want if their condition was “reversible/acceptable”
and the type of care they would want if their condi-
tion was “irreversible/intolerable.” Practical examples
are provided.
3. Competency is then assessed. Each resident’s
capacity to complete the LMD-ACD was assessed
using the Screening Instrument to Assess Capac-
ity to Complete an Advanced Directive [25, 28]. e
expected high prevalence of cognitive impairment
in the LTC population [29] underlined the need to
include this assessment of resident capacity as a criti-
cal step in the completion of a valid ACD. When resi-
dents lacked capacity to complete ACD’s, their end-
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O’Sullivan et al. BMC Res Notes (2016) 9:237
of-life care choices were discussed. Where possible,
the resident was included in this discussion together
with their family (with the residents permission).
In some instances the resident was unable through
severe impairment of cognition to participate. In
these circumstances their families were invited to
discuss end-of-life care choices, taking consideration
of any previously expressed wishes of the resident or
with knowledge of the resident and their values, what
they felt the resident would have wanted. Encapsulat-
ing the decisions discussed, and with the agreement
of those involved, an end-of-life care plan was com-
pleted by the resident’s doctor and nurse.
4. Once the resident is deemed competent, choices
are reviewed and documented on the directive. e
directive is then signed by the patient, substitute
decision makers (usually family), and physician.
Economic analysis
An economic (gross costs) analysis was performed to
estimate the economic impact of reduced hospitalisa-
tions anticipated with the implementation of the LMD-
ACP. is cost analysis employed standard techniques
that required the identification, measurement and valua-
tion of resources as per Drummond etal. [30]. Resources
identified were inpatient hospitalisations (by episode and
length of admission) and ambulance transfers. To meas-
ure resources used, results were employed to estimate
the probability of hospitalisations among nursing home
residents prior to and post implementation of LMD-
ACP. Length of stay (LOS) was estimated and each hos-
pitalisation was associated with an ambulance transfer.
With regards to valuing the resources employed, sec-
ondary data were employed to estimate the average cost
per episode [31], average per diem cost [31] and cost of
ambulance transfer [32]. An average per diem cost was
estimated to account for the variation between national
average LOS associated with the inpatient casemix cost
and the LOS indicated in this study.
Scenario analyses were used to investigate the effect of
changes to LOS and gross cost per diem. Firstly, LOS is
varied using admission evidence from a hospital admis-
sions database (a large, university teaching hospital and
level one trauma centre, covering southern Ireland and
serving a population of more than 1,173,000 people),
used as a reference point to provide LOS data on trans-
fers from nursing homes for the same time periods as the
LMD-ACP study. Secondly, the per diem rate estimated
in the baseline analysis, which may be considered con-
servative relative to estimates employed in other studies.
For example, the Strategy for Long Term Care in Ire-
land estimated the cost of acute care to be 6000/week,
which would be 857/day, based on BDO International
auditors’ data [33]. e per diem gross cost was also var-
ied to determine the effect on the results if a higher cost
was used. Finally, a probabilistic sensitivity analysis was
performed as a means of addressing usual uncertain-
ties surrounding parameters like those employed in this
study. is required characterising uncertainty in input
parameters and propagating uncertainty through the
model using a Monte Carlo simulation. e results of this
present the implications of parameter uncertainty [34].
Statistical analysis
Descriptive statistics were used to summarise hospital
days and death counts in the three LTC units for each
project phase: baseline (January 2010–June 2012), and
post-implementation (July 2013–June 2015). e imple-
mentation phase (between these two phases) during
set-up of the study was examined separately and is not
included in this analysis as this was the time when educa-
tion was provided and staff were becoming familiar with
implementing the LMD-ACP process, i.e. it was a edu-
cation phase. In addition to counts, four ratios (propor-
tions) for each project phase were calculated:
Annual death rate (number of deaths per year÷aver-
age number of residents across all three nursing
units).
Percentage of deaths in hospital (number of hospital
deaths÷total number of deaths).
Hospitalisation rate based on incidents of hospitali-
sation (number of hospitalisations per year÷average
number of residents across all three nursing units).
Hospitalisation rate based on inpatient hospital days
(hospital bed days÷number of resident days).
For the purpose of analysis, we compared rates in the
post intervention phase with the baseline (pre inter-
vention) phase. As the study was designed to explore a
decline in each of the three rates in the post-intervention
phase, a series of one-sided z-tests for independent sam-
ples proportions was conducted comparing rates in the
baseline phase with the post-intervention phase.
Results
e number of deaths, the number of days in acute hos-
pital care (hospital bed days per resident) and the ratios
for each phase of the project in all three pilot nurs-
ing homes are provided in Table1. Two of the homes
added new beds during the study necessitating the use
of percentages and rates in the analyses because the
absolute number of residents changed during the study
period. At baseline 290 residents were available and this
increased to 304 at the beginning of the post implemen-
tation phase. All residents were aged over 65years. eir
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O’Sullivan et al. BMC Res Notes (2016) 9:237
characteristics did not change significantly between the
pre and post-implementation phases. e mean age
was 85.9 years. e majority were female (67.3 %) and
the most had cognitive impairment (mean Abbrevi-
ated Mental Test Score 3.3/10). Of those that died, more
than three quarters of respondents (76.5%) were with a
relative. Only three residents across all study sites were
excluded as they were aged <65years. e participation
rate of those who received information varied. Prior to
the study, 25% had some form of end-of-life care plan in
place. is increased to 76% post implementation, rang-
ing from 57 to 90% across the three sites (12% of these
were ACDs completed by the residents). Only 10% of
residents were deemed to have had capacity to complete
their own ACD. In all, 84% of those who died during the
post-implementation period had an end-of-life care plan
in place, compared to 89% of residents who died in the
nursing homes, while 50% of those who died following
transfer to acute care had one in place. In total, four resi-
dents who had an end-of-life care plan died in an acute
hospital; three of these stated that these residents would
decline hospital transfer.
Combining data from the three nursing homes revealed
a decrease in the annual mortality rate, from 30.3% at
baseline to 27.6 % in the post-implementation phase,
which was not statistically significant z=0.74, p=0.23.
ere was a significant decline in the proportion of
deaths in hospital, from 22.9% at baseline to 8.4% post-
implementation, z= 3.22, p = 0.001. ere was also a
significant reduction, by almost half, in hospitalisation
rates. Hospitalisation, derived from number of incidents,
decreased from 27.9 to 14.6% between baseline and post-
implementation, z=3.93, p<0.001; hospitalisation cal-
culated by the number of hospital days declined from
0.54 to 0.36 % from baseline to post-implementation,
z=8.85, p<0.001. ese results are shown in Table2.
Economic cost ofall hospitalisations
e direct gross costs associated with hospitalisations of
nursing home residents include inpatient costs and ambu-
lance transfer costs. At baseline (January 2010 to June
2012), the probability of hospitalisations per resident was
0.28 per annum on average. is reduced to 0.15 post
implementation of theLMD-ACP process(July 2013–June
2015) on average per annum. e average LOS of these
hospitalisations however, increased from seven at baseline
(January 2010–June 2012) to nine post implementation of
theLMD-ACPprocess (July 2013–June 2015).
Reasons for admission included pneumonia, chronic
obstructive pulmonary disease, urosepsis, stroke, cardiac
failure and bowel obstruction. e associated diagnosis
related groups (DRGs) were collected from the Ready
Reckoner [31] and using the inpatient casemix cost per
case, an average cost per episode was estimated at 4081
(standard deviation 3328). Averaging the costs per
DRG across the national average LOS, yielded an aver-
age daily cost of 491 (standard deviation 59). e cost
Table 1 Hospitalisations, length of stay (LOS) anddeaths
acrossthe three long-term care units including compari-
son withreference site
Pre-implementation Post-implementation
Months 30 24
Number of beds
(excluding those
declining to
participate)
287 301
Deaths per year
(average) 87 83
Annual death rate
(average) 30.3 % 27.6 %
Deaths in Hospital
(average per year) 8 7
Percentage of deaths in
hospital (average) 22.9. % 8.4 %
Total deaths 218 166
Hospitalisations per year 80 44
Hospitalisation rate
(based on hospitalisa-
tion incidents)
27.9 % 14.6 %
Average LOS per stay 7.02 9.07
Average LOS for same
period in reference
hospital site amongst
those transferred from
nursing homes
9.89 8.58
Hospital bed days
(per month) 1403 (46.8) 798 (33.3)
Hospitalisation rate
(based on hospital
days)
0.54 % 0.36 %
Table 2 Statistical comparison ofoutcomes (average annual rate) betweenpre andpost implementation phases
Pre-implementation (%) Post-implementation (%) One -sided z-test
Annual death rate (average) 30.3 27.6 z = 0.74, p = 0.23
Percentage of deaths in hospital (average per year) 22.9 8.4 z = 3.22, p = 0.001
Hospitalisation rate (average per year based on hospitalization incidents) 27.8 14.6 z = 3.96, p < 0.001
Hospitalisation rate (average per year based on hospital days) 0.54 0.36 z = 8.85, p < 0.001
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Page 6 of 10
O’Sullivan et al. BMC Res Notes (2016) 9:237
of ambulance transfers, sourced from Gannon etal. and
adjusted for inflation is estimated to be 97/transfer [32].
Nursing Home Ireland indicates the population of
nursing home residents to be 33,000. Extrapolating the
results of the LMD-ACP study to the nursing home pop-
ulation in Ireland, the expected change in hospitalisation
costs owing to reduced hospitalisations can be estimated.
Expected hospitalisations pre-implementation of LMD-
ACP for this population is estimated to be 9186 annu-
ally. Applying the average cost per episode (4081) to this
yields an average cost of 37.5 million per annum (gross).
If the reduced probability of hospitalisations of 0.15 were
to persist, hospitalisations amongst nursing home resi-
dents would be reduced to 4824 per annum. Applying the
average cost per episode to this yields an average cost of
19.7 million per annum, indicating a cost reduction of
17.8 million (gross). In addition, ambulance transfers
would be reduced by 4362, yielding a further cost reduc-
tion of 423,453 per annum (gross). Alternatively, if the
cost of inpatient hospitalisations was estimated using
the daily average cost (491/day) using LOS results from
this study, the expected cost reduction per annum is a
more conservative 10.2 million per annum (gross). is
reflects that the LOS amongst nursing home residents is
less than the national average per DRG. ese results are
summarised in Table3.
Scenario analysis
e sensitivity of the analysis was tested by varying two
parameters in a scenario analyses: LOS and per diem
cost. Firstly, the baseline analysis above employed LOS
evidence from this study, which indicated an increase in
average LOS between baseline (January 2010–June 2012)
and post implementation of LMD-ACP (July 2013–June
2015). However, evidence from the university hospital
reference sites’ database reveals that for the same periods:
baseline (January 2010–June 2012) and post implementa-
tion of theLMD-ACP process(July 2013–June 2015), the
average LOS for residents admitted from nursing homes
decreased from 9.89 to 8.58 days. Adjusting for these
LOS data increases the expected cost reduction to 24.3
million (gross) (Scenario analysis 1).
Secondly, in the absence of a national cost reference
database, it is not a surprise that hospitalisation costs
vary between analyses. e per diem rate estimated in
the baseline analysis above (491) is conservative rela-
tive to estimates employed in other studies. For example,
the Strategy for Long Term Care in Ireland estimated
the cost of acute care to be 6000/week, which would be
857/day [33]. Applying this higher cost per diem to the
LOS estimates from this study indicates an expected cost
reduction of 17.7 million (gross) (Scenario analysis 2).
A third scenario analysis considers the effect of employ-
ing LOS data from the reference hospital and the average
per diem cost of 857/day. Here the expected cost reduc-
tion, owing to reduced hospitalisations, is 42.4 million
(gross) (Scenario analysis 3). ese are summarised in
Table4.
Probabilistic sensitivity analysis
To account for parameter uncertainty a probabilistic sen-
sitivity analysis (PSA) was performed. e results includ-
ing upper and lower percentiles at the 95% confidence
level for the baseline cost analyses and the scenarios
are summarised on Table5 and show that for the base-
line analysis and scenario analyses implementation of
theLMD-ACPprogramme continues to yield an average
cost reduction owing to reduced hospitalisations. How-
ever, where LOS from the pilot study is used, the PSA
identifies some uncertainty surrounding the cost reduc-
tion. Nevertheless, the results of the PSA indicate that
there is an 89% probability that costs will be reduced and
Table 3 Economic cost analysis: comparison pre andpost implementation ofthe Let Me Decide Advanced Care Planning
(LMD-ACP) programme (gross costings)
a Based on data from this LMD-ACP study
b Based on 33,000 nursing home beds nationally
c Based on average inpatient case mix cost across common diagnosis related groups (DRGs)
d Daily average from inpatient case mix cost across common DRGs
e Gannon etal. [32]
Unit ofanalysis Parameter Pre implementation
(Jan 2010–Jun 2012) Post implementation
(July 2013–Jun 2015) Dierence
Probability of Hospitalisation per residenta0.28 0.15
Total Hospitalisation Episodes Nationallyb9186 4824 4362
Length of Stay LMD-ACP 7.02 9.07 2.05
a. Episode of care 4081/Episodec37,487,265 19,686,419 17,800,847
b. Length of stay 491/day DRGd31,630,876 21,472,704 10,158,173
Ambulance transfers 97/transfere891,761 468,308 423,453
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 7 of 10
O’Sullivan et al. BMC Res Notes (2016) 9:237
11% probability that the increased LOS increases costs.
However, when episode of care or LOS from therefer-
ence hospital database is used to estimate inpatient costs,
there is a 100% probability that costs are reduced.
Discussion
is paper presents the economic cost impact of the sys-
tematic implementation of the LMD-ACP programme in
three LTC facilities in the south of Ireland. Hospitalisa-
tions and deaths were measured for two and half years
before (baseline i.e. pre-implementation) and two years
after the programme was implemented (post-implemen-
tation phase). e results show that there was a signifi-
cant reduction in hospital transfers and number of days
residents spent in hospital following the implementa-
tion of the programme, comparing the two phases. ere
was also a reduction of in-hospital deaths, although this
did not reach statistical significance. e results of this
study enable us to estimate the gross cost burden associ-
ated with the decision to transfer LTC residents to hos-
pital. Inpatient admissions and ambulance transfers were
quantified directly and invasive interventions indirectly,
amongst those who had in-hospital deaths. Given the
anticipated reductions in hospitalisations, the expected
cost reductions ranged between 10 and 17.8 million
per annum (gross) with an additional 0.4 million for a
reduction in ambulance transfers, depending on which
costing methodology is used. e rationale for using unit
costs per episode, which results in projected savings of
approximately 17.8 million per year (gross), if the LMD-
ACP programme were introduced nationwide in Ireland,
lies in the planned shift towards activity based costing
envisaged for the Irish healthcare system, whereby costs
will be based on episodes of care. However, at present
until activity based costing becomes a reality in Ireland,
LOS as a unit of analysis is a more conservative and pos-
sibly realistic estimate. e results of the PSA reaffirm
the cost savings.
e three scenarios presented in the scenario analysis
all result in large savings due to a projected reduction in
hospitalisations. is is despite an increased LOS, which
likely reflects an increased casemix associated with more
complex inpatient management for those who required
hospital transfer. us, even though LOS increased, the
number of bed days used overall reduced.
Given the lack of a reference cost database, it is diffi-
cult to calculate the exact cost of a bed day in Ireland—to
account for this uncertainty, a range is provided: the con-
servative estimate of 491 per day and the more expen-
sive 857 per day rate based upon DRGs (see Table3).
Irrespective of which cost estimate per day is used, the
savings are substantial. With regards to the use of LOS
estimates, the increased LOS in the trial, we found that
this wasn’t in line with the local reference hospital (a uni-
versity hospital tertiary referral centre) trends during the
period, so the scenario analysis considers cost if the num-
ber of hospitalisations were to reduce without impacting
LOS. e two baseline analyses and the scenario analy-
sis all suggest the same conclusion, although to varying
amounts depending on the LOS and rates used, with the
potential cost savings likely to be between 10 and 42
million annually (gross).
e findings of this study are similar to other stud-
ies looking at end-of-life planning. In the United States,
end-of-life discussions alone, without using a specific
ACP programme, resulted in a 35% reduction in costs
in the last week of life, albeit for patients with advanced
cancer [23]. In Singapore, ACP as part of a programme
to improve end-of-life care for nursing home residents
found a per-resident cost savings of SGD$7129 (con-
fidence interval: SGD$4544–SGD$9714) over the last
3months of life [17].
Based upon a previous qualitative assessment, the
LMD-ACP and palliative care education programmes
were well received by the staff of these units [24] and resi-
dents and their families [25]. Following implementation,
Table 4 Scenario analysis: comparison pre andpost implementation ofthe Let Me Decide Advanced Care Planning (LMD-
ACP) programme (gross costings)
a Based on reference hospital length of stay (LOS) data
b Based on LMD-ACD LOS data
c Daily average from inpatient case mix cost across common diagnosis related groups (DRGs)
d BDO International auditors’ data [33]
Scenario Pre implementation
(January 2010–June 2012) Post implementation
(July 2013–June 2015) Dierence
1. LOS—reference hospital dataa and 491/dayc44,594,350 20,304,890 24,289,461
2. LOS—LMD-ACD datab and 857/dayd55,232,926 37,495,017 17,737,909
3. LOS—reference hospital data and 857/dayd77,869,371 35,455,814 42,413,557
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 8 of 10
O’Sullivan et al. BMC Res Notes (2016) 9:237
the uptake of some form of ACP (ACDs or end-of-life care
plans) in the three homes increased to 90% of residents.
In this study, 10% of residents had capacity to complete
their own ACD. For those who lacked capacity, end-of-life
care plans were completed by the medical team, following
discussions with the family and with the resident where
possible. is is compatible with current Irish law. Nurs-
ing staff reported that, in general, families were very keen
to be involved in the end-of-life care planning process and
that families of residents who lacked capacity to complete
an ACD or ACP consistently asked for low levels of inter-
vention for their relative at the end-of-life. e majority
requested that the resident should not be transferred to
acute care hospitals, and be kept in the nursing home at
the end-of-life, if possible. Following implementation of
the programme, feedback from staff indicated that a lack
of time to deliver ACP was one of the biggest challenges
they encountered, particularly for those with cognitive
impairment, and that protected time would be helpful to
deliver ACP effectively in an unhurried manner [24].
is study has a number of limitations that provide
reasons to be cautious about the estimates provided. e
greatest limitation is that it was a before-after interven-
tion study with the LTC units acting as their own histori-
cal controls (only the time period varied) and that baseline
and end-point demographic data were not routinely avail-
able. is may have introduced bias in that the character-
istics of patients including their health status may have
changed, likely deteriorating over time. at said, this
would favour the null and serve to potentially strengthen
the data supporting a reduction in hospitalisations and
length of stay. is could also create potential bias in that
the effects seen might reflect other changes in hospital
admission and healthcare policy locally, and on a national
level in Ireland. To gain some historical controls other
than these homes themselves we reviewed hospitalisation
rates into the regions tertiary referral centre, as a refer-
ence site, and found that there was no significant change
in hospitalisations from LTC facilities during this period.
If anything, there was a trend towards an increase in hos-
pitalisations from LTC facilities. is may reflect system
changes such as alterations to data collection or coding,
potentially limiting the results of this study. e scenario
analysis presented here including aggregated level data
is theoretical to consider the possible gross savings if the
preliminary results presented were confirmed. us, to
confirm the cost saving estimates presented here, a RCT is
required. Further, this paper presents the results from dif-
ferent costing approaches, which may have over or under-
estimated savings. Choosing which costing methods to
employ is challenging and any inference made, where
the marginal effect of explanatory variables is assessed,
is substantially influenced by the costing method [35].
Different models were presented in this paper although
others may have more accurately reflected potential cost
savings. In addition, no data were available on the cost of
implementation limiting this study to a gross cost analy-
sis rather than a full evaluation. Finally, the question of
appropriateness of hospitalisation wasn’t addressed in this
study. While it is possible that this intervention may have
resulted in inappropriate decisions to withhold transfer,
as this study was conducted rigorously as a clinical trial
and supervised by a steering committee, which examined
each decision to transfer afterwards, it is unlikely that
residents care was unduly affected. Following implemen-
tation of the programme a decision to transfer out was
Table 5 Results fromprobabilistic sensitivity analysis: average costs andupper andlower percentiles (gross costings)
a Based on reference hospital length of stay (LOS) data
b Based on LMD-ACP LOS data
c 4081—based on average inpatient case mix cost across common diagnosis related groups (DRGs)
d 491/day—daily average from inpatient case mix cost across common DRGs
e 97/transfer Gannon etal. [32]
f 857/day—BDO International auditors’ data [33]
Analysis Pre implementation
(January 2010–June 2012)
average millions (lower
andupper percentiles 95%)
Post implementation
(July 2013–June 2015) average
millions (lower andupper
percentiles 95%)
Dierence average
millions (lower
andupper
percentiles 95%)
a. Baseline: 4081/episode of hospitalisationc37.82 (2.65–119.34) 19.87 (1.37–64.10) 17.95 (1.15–58.90)
b. Baseline: LMD-ACP LOSa and 491/dayd32.49 (18.96–52.34) 21.83 (12.46–35.40) 10.67 (6.10–30.69)
Ambulance transferse0.89 (0.55–1.34) 0.47 (0.27–0.73) 0.42 (0.19–0.73)
Scenario analyses
1. LOS—reference hospital datab and 491/dayf44.69 (25.84–70.51) 20.30 (13.75–28.31) 24.39 (6.05–48.55)
2. LOS—LMD-ACD Dataa and 857/dayf56.71 (34.61–87.58) 38.11 (22.48–60.20) 18.60 (10.87–52.14)
3. LOS—reference hospital datab and 857/dayf77.98 (47.24–118.78) 35.43 (25.59–47.01) 42.55 (10.72–83.16)
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 9 of 10
O’Sullivan et al. BMC Res Notes (2016) 9:237
made in advance and in the majority of cases competent
patients or families of incompetent patients requested
that the person should stay in the nursing home and not
be transferred. In this case patients remained unless they
could not be kept comfortable in the unit. In the event of
an unexpected event, each decision to transfer was made
by the nursing staff and the primary care physician super-
vising the unit in conjunction with the resident and or the
family members on a case-by-case basis with reference
to the patients stated preferences. On the other hand,
prior to this study when a resident became acutely ill, the
decision to transfer was made by a primary care physi-
cian. Prior to implementation 25% had either an end-of-
life care plan or an ACD, which in the majority of cases
was a ‘do not attempt resuscitation’ order and did not
address transfer. In these cases the default position was
the transfer of the patient. Several studies have examined
the proportion of hospital admissions of nursing home
residents that were inappropriate or avoidable [36, 37].
A study in the United Kingdom looking at the cost sav-
ing represented by potentially avoidable admissions (35 of
483 admissions), by caring for such patients in alternative
locations found it would have saved approximately £5.9
million per year for the two hospitals involved with the
study [38].
Conclusions
In summary, this before-after trial suggests that there was
a significant reduction in hospitalisation rates following
the systematic implementation of the LMD-ACP and pal-
liative care education programme in three LTC facilities
in southern Ireland. It shows that there were significant
cost savings associated with this reduction in admissions.
Despite an increase in average LOS, likely reflecting more
complex care needs of admitted residents, costs were
estimated to be reduced and scenario analysis projected
large significant annual cost savings associated with this
reduction in admissions. e economic cost analysis indi-
cates that should the reduced hospitalisations amongst
LTC residents as a result of theLMD-ACP process be
transferrable to the general LTC population in Ireland
then it has the potential to substantially reduce inpatient
and ambulance transfer costs. Such cost reductions were
consistent when costing per diem or per episode and
using a range of costs. is expands and strengthens find-
ings from two other RCTs in Canada and Australia and
supports the generalisability of these findings. A rand-
omized trial of this programme in now underway in Ire-
land to confirm the findings of this pilot study.
Abbreviations
ACD: advanced care directives; ACP: advance care planning; DRGs: diagnosis
related groups; LOS: length of stay; LMD: Let Me Decide; LTC: long-term care;
PSA: probabilistic sensitivity analysis; RCT: randomised controlled trials; SGD:
Singapore dollar; SMMSE: Standardised Mini-Mental State Examination.
Authors’ contributions
Study concept and design: CMG, DWM. Subject information data: CMG, NC.
Data analysis and interpretation: AM, AS, DWM, CMG, RO’C. Initial drafting of
the manuscript: RO’S, RO’C, DWM. Editing and re-reviewing the final manu-
script: RO’C, AM, CMG, DWM, NC, BD, CT, CF. All authors read and approved the
final manuscript.
Author details
1 Centre for Gerontology and Rehabilitation, University College Cork, St
Finbarrs Hospital, Cork City, Ireland. 2 School of Economics, University Col-
lege Cork, College Road, Cork City, Ireland. 3 Health Research Board, Clinical
Research Facility Galway, National University of Ireland, Galway, Geata an
Eolais, University Road, Galway City, Ireland. 4 COLLAGE (COLLaboration
on AGEing), University College Cork, Cork City, Ireland. 5 Catherine McAuley
School of Nursing and Midwifery, University College Cork, Cork, Ireland. 6 UZIK
Consulting Inc., 86 Gerrard St E, Unit 12D, Toronto, ON M5B 2J1, Canada. 7 Col-
lege of Medicine and Health, Brookfield Health Sciences Complex, University
College Cork, College Road, Cork City, Ireland.
Acknowledgements
The authors wish to thank the residents, their families and the staff of the long
term care sites for facilitating and taking part in this research. The research
team also extend their gratitude to the Irish Hospice Foundation for providing
funding to conduct this research.
Competing interests
Prof D. William Molloy is the copyright holder of the Let Me Decide advance
care planning programme.
Funding
The Centre for Gerontology and Rehabilitation is supported by Atlantic Philan-
thropies, the Health Service Executive of Ireland, the Health Research Board of
Ireland and the Irish Hospice Foundation.
Received: 17 March 2016 Accepted: 18 April 2016
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... Of 11 end-of-life care studies that provided data on hospital transfers/admissions, nine explicitly sought to reduce these (Chapman et al., 2018;Garden et al., 2016;Hockley et al., 2010;Kinley et al., 2018;Kuhn & Forrest, 2012;Kunte et al., 2017;Luk & Chan, 2017;O'Sullivan et al., 2016;Teo et al., 2014). Six studies favoured the intervention (Garden et al., 2016;Kinley et al., 2018;Kunte et al., 2017;Luk & Chan, 2017;O'Sullivan et al., 2016;Teo et al., 2014). ...
... Of 11 end-of-life care studies that provided data on hospital transfers/admissions, nine explicitly sought to reduce these (Chapman et al., 2018;Garden et al., 2016;Hockley et al., 2010;Kinley et al., 2018;Kuhn & Forrest, 2012;Kunte et al., 2017;Luk & Chan, 2017;O'Sullivan et al., 2016;Teo et al., 2014). Six studies favoured the intervention (Garden et al., 2016;Kinley et al., 2018;Kunte et al., 2017;Luk & Chan, 2017;O'Sullivan et al., 2016;Teo et al., 2014). ...
... Taxonomies of specialist care home support and support in palliative care and/or advance care planning (Baron et al., 2015;Brännström et al., 2016;Covington, 2013;Cox et al., 2017;Hockley & Kinley, 2016;Kinley et al., 2014Kinley et al., , 2018O'Sullivan et al., 2016;Reymond et al., 2011), of which four drew on the Gold Standards Framework quality improvement training programmes (Baron et al., 2015;Covington, 2013;Hockley & Kinley, 2016;Kinley et al., 2014), and others the (subsequently phased out) Liverpool ...
Article
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Aim To synthesize evidence on the ability of specialist care home support services to prevent hospital admission of older care home residents, including at end of life. Design Systematic review, without meta-analysis, with vote counting based on direction of effect. Data sources Fourteen electronic databases were searched from January 2010 to January 2019. Reference lists of identified reviews, study protocols and included documents were scrutinized for further studies. Review methods Papers on the provision of specialist care home support that addressed older, long-term care home residents’ physical health needs and provided comparative data on hospital admissions were included. Two reviewers undertook study selection and quality appraisal independently. Vote counting by direction of effect and binomial tests determined service effectiveness. Results Electronic searches identified 79 relevant references. Combined with 19 citations from an earlier review, this gave 98 individual references relating to 92 studies. Most were from the UK (22), USA (22) and Australia (19). Twenty studies were randomized controlled trials and six clinical controlled trials. The review suggested interventions addressing residents’ general health needs (p < .001), assessment and management services (p < .0001) and non-training initiatives involving medical staff (p < .0001) can reduce hospital admissions, while there was also promising evidence for services targeting residents at imminent risk of hospital entry or post-hospital discharge and training-only initiatives. End-of-life care services may enable residents to remain in the home at end of life (p < .001), but the high number of weak-rated studies undermined confidence in this result. Conclusion This review suggests specialist care home support services can reduce hospital admissions. More robust studies of services for residents at end of life are urgently needed. Impact The review addressed the policy imperative to reduce the avoidable hospital admission of older care home residents and provides important evidence to inform service design. The findings are of relevance to commissioners, providers and residents.
... Previous studies have found positive effects of ACPs in NH patients, such as fewer hospital admissions (61-63), medical treatments consistent with patients' wishes (61, 64), a higher incidence of preferred place of death (63) and reduced healthcare costs (61,62). In a systematic review of the effects of ACPs in a NH context, Martin et al. (55) showed that ACP decreased hospitalisations by 9-26% and led to a significant increase, of 29-40%, in the number of patients dying in their NH. ...
... The facts that a high proportion of deaths in Sweden, and in several other countries, take place in NHs (14,(18)(19)(20), and that positive effects of ACPs have been shown previously (53,55,(61)(62)(63)(64)(65)(66)(67), make it especially important to study physicians' and nurses' perspectives on the factors that shape the ACP process in a NH context. ...
... Eine zeitnahe palliative Anbindung des/der Bewohner:in z. B. durch frühzeitige Konsultationen, Kommunikation mit palliativmedizinisch weitergebildeten Pflegekräften und verbesserte Symptomkontrolle kann die Häufigkeit von Krankenhauszuweisungen verringern [42,43]. ...
Article
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Zusammenfassung Hintergrund Pflegeheimbewohner:innen werden häufiger hospitalisiert als nicht institutionalisierte Gleichaltrige. Eine Vielzahl an Rettungsdiensteinsätzen und Krankenhauszuweisungen wird als potenziell vermeidbar eingeordnet. Ziele der Arbeit Zuweisungsbegünstigende Begleitumstände bei Notfallsituationen in Pflegeeinrichtungen sowie Ansätze zur Reduktion von Krankenhauszuweisungen sollen identifiziert werden, um die Komplexität der Versorgungsprozesse und Handlungsperspektiven aufzuzeigen. Material und Methoden Scoping-Review mit Analyse aktueller Original- und Übersichtsarbeiten (2015–2020) in den Datenbanken PubMed, CINAHL sowie per Handsuche. Ergebnisse Aus 2486 identifizierten Studien wurden 302 Studien eingeschlossen. Verletzungen, Frakturen, kardiovaskuläre und respiratorische Erkrankungen sowie Infektionskrankheiten sind die häufigsten retrospektiv erfassten Diagnosegruppen. Hinsichtlich der einweisungsbegünstigenden Umstände konnten verschiedene Aspekte identifiziert werden: bewohnerbezogene (z. B. Multimorbidität, fehlende Patientenverfügungen), einrichtungsbezogene (u. a. Personalfluktuation, Unsicherheiten), arztbezogene (z. B. mangelnde Erreichbarkeit, erschwerter Zugang zu Fachärzt:innen) und systembedingte (z. B. eingeschränkte Möglichkeiten zur Diagnostik und Behandlung in Einrichtungen). Verschiedene Ansätze zur Verminderung von Krankenhauszuweisungen sind in Erprobung. Diskussion Vielfältige Begleitumstände beeinflussen das Vorgehen in Notfallsituationen in Pflegeeinrichtungen. Interventionen zur Reduktion von Krankenhauszuweisungen adressieren daher u. a. die Stärkung der Kompetenz des Pflegepersonals, die interprofessionelle Kommunikation und systemische Ansätze. Ein umfassendes Verständnis der komplexen Versorgungsprozesse ist die wesentliche Grundlage für die Entwicklung und Implementierung effektiver Interventionen.
... Advance care planning is also seen as central to supporting care efficiency, as this promotes coordination and preparation for an advancing health trajectory (233). In the United States, it is estimated that the prioritisation of advance care planning may actively reduce costs associated with intensive care at the end of life by 25% (234) In Ireland, it has been suggested that advance care planning is associated with lower hospitalisation rates and potential savings on a national scale, if implemented country-wide (235). Since the publication of the NACPC report, 'Think Ahead', a specific advance care planning project was established by the Irish Hospice Foundation and launched in phased progression in 2011. ...
Technical Report
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The Programme for Government of June 2020 commits to publishing a new palliative care policy for adults with the aim of ensuring universal provision of high-quality, integrated services based on need for people with life-limiting illness and their loved ones. Progressing the Policy Update is also a commitment in the Sláintecare Implementation Strategy and Action Plan 2021-2023 and the Department of Health’s Statement of Strategy 2021-2023. The aim of this study is to inform this planned revision of Ireland’s national palliative care policy by examining the implementation of existing national palliative care policy and identifying priority areas that should be addressed. This review provides a complementary source of evidence to two other studies commissioned by the Department of Health. These are the Health Research Board International Evidence Brief of palliative care policy; and a report of the findings of a public consultation seeking views on palliative care services in Ireland and priorities for the new palliative care policy.
... Previous studies have shown positive effects of advance care planning in EOL care, such as reduced hospital admissions, decreased number of days spent in hospital, place of death in accordance with patient preferences and positive economic aspects [3][4][5][6][7]. Detering et al. showed that advance care planning in elderly hospitalised patients was associated with improved quality of life and reduced aggressive/intensive care at EOL [3]. ...
Article
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Objective: Studies on advance care planning in nursing homes are rare, and despite their demonstrated favourable effects on end-of-life care, advance care plans are often lacking. Therefore, we wished to explore: (i) the prevalence of advance care plans in a Swedish nursing home setting using two different definitions, (ii) the content of advance care plans, (iii) adherence to the content of care plans and (iv) possible associations between the presence of advance care planning and background characteristics, physician attendance and end-of-life care. Design: Retrospective chart review. Setting: Twenty-two nursing homes in Sweden. Subjects: A total of 367 deceased patients (included between 1 June 2018 and 23 May 2020) who had lived in nursing homes. Main outcome measures: Electronic health record data on the prevalence of advance care plans with two different definitions and variables regarding background characteristics, physician attendance and end-of-life care, were collected. Results: Of the study population, 97% had a limited care plan (ACP I) documented. When using the comprehensive definition (ACP II), also including patient's preferences and involvement of family members in advance care planning, the prevalence was 77%. Patients with dementia more often had care plans, and a higher physician attendance was associated with presence of advance care plans. Prescription of palliative drugs and information to family members of the patient's deterioration and impending death were more common in patients with care plans compared to those where such plans were missing. There was adherence to the care plan content. Conclusion: In contrast to previous research, this study showed a high prevalence of advance care plans in nursing home patients. Patients with care plans more frequently received prescriptions of palliative drugs and their family members were informed to a greater extent about the patient's deterioration and impending death compared to those without care plans. These aspects are often seen as vital components of good palliative care.Key pointsStudies on advance care planning in nursing homes are rare, and despite their demonstrated positive effects on end-of-life care, advance care plans are often lacking.The present study revealed a high prevalence of advance care plans (77-97% depending on definition) in nursing home patients.Patients with dementia more often had advance care plans, and a higher physician attendance was associated with presence of care plans.Advance care plans were positively associated with components of good palliative care, such as prescriptions of palliative drugs and information to family.
... ACP juga dapat memengaruhi dalam penurunan biaya kesehatan (Yadav et al., 2017), menurunkan tingkat hospitalisasi, dan mengurangi penggunaan alat medis dan obat-obatan yang sia-sia (Dixon, Matosevic, & Knapp, 2015;O'Sulivan et al., 2016). Pada proses ACP, perawat memegang peran penting untuk mengkaji kondisi pasien, inisiator, penyedia informasi, edukator, komunikator, fasilitator, advokator, dan manajer kasus dalam ACP (Ke et al., 2015). ...
Book
Modul ini berisi terjemahan dari sebuah alat ukur, yaitu WPACP. Alat ukur ini merupakan alat ukur yang dapat diisi sendiri oleh perawat dalam menilai kesediaan perawat paliatif dalam mengembangkan ACP dalam tatanan paliatif. Alat ukur ini tidak bertanya tentang pengetahuan atau keterampilan khusus dari perawat sehingga cukup mudah diisikan oleh perawat.
... Inpatient and day case hospital costs are calculated using detailed bottom-up methods and there are plans to expand activity-based funding to acute outpatient services 2 . Several Irish costing studies have used the casemix costs published by the HPO (e.g., Butler et al., 2016;Connolly et al., 2015;O'Sullivan et al., 2016). ...
Article
Background: This paper presents detailed unit costs for 16 healthcare professionals in community-based non-acute services in Ireland for the years 2016—2019. Unit costs are important data inputs for assessments of health service performance and value for money. Internationally, while some countries have an established database of unit costs for healthcare, there is need for a more coordinated approach to calculating healthcare unit costs. In Ireland, detailed cost analysis of acute care is undertaken by the Healthcare Pricing Office but to date there has been no central database of unit costs for community-based non-acute healthcare services. Methods: Unit costs for publicly employed allied healthcare professionals, Public Health Nurses and Health Care Assistant staff are calculated using a bottom-up micro-costing approach, drawing on methods outlined by the Personal Social Services Research Unit in the UK, and on available Irish and international costing guidelines. Data on salaries, working hours and other parameters are drawn from secondary datasets available from Department of Health, Health Service Executive and other public sources. Unit costs for public and private General Practitioner, dental, and long-term residential care (LTRC) are estimated drawing on available administrative and survey data. Results: The unit costs for the publicly employed non-acute healthcare professionals have changed by 2–6% over the timeframe 2016–2019 while larger percentage changes are observed in the unit costs for public GP visits and public LTRC (14-15%). Conclusions: The costs presented here are a first step towards establishing a central database of unit costs for non-acute healthcare services in Ireland. The database will help ensure consistency across Irish health costing studies and facilitate cross-study and cross-country comparisons. Future work will be required to update and expand on the range of services covered and to incorporate new data and methodological developments in cost estimation as they become available.
... Phase two involved presenting the initial findings to the participants (from phase one) using focus groups and semi-structured interviews. Murray et al. (2009) found that the use of repeating or serial interviews helped to uncover the complexities of individual situations by allowing narratives to develop. ...
Article
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Aims To evaluate care planning in advance of end‐of‐life care in care homes. Design A qualitative study. Methods Qualitative data were collected from January 2018–July 2019 (using focus groups and semi‐structured interviews) from three care homes in the South West of England. The data were analysed using thematic analysis followed by Critical Realist Evaluation. Results Participants comprised of registered nurses (N = 4), care assistants (N = 8), bereaved relatives (N = 7), and domiciliary staff (N = 3). Although the importance of advance care planning was well recognized, the emotional labour of frequently engaging in discussions about death and dying was highlighted as a problem by some care home staff. It was evident that in some cases care home staff's unmet emotional needs led them to rushing and avoiding discussions about death and dying with residents and relatives. A sparsity of mechanisms to support care home staff's emotional needs was noted across all three care homes. Furthermore, a lack of training and knowledge appeared to inhibit care home staff's ability to engage in meaningful care planning conversations with specific groups of residents such as those living with dementia. The lack of training was principally evident amongst non‐registered care home staff and those with non‐formal caring roles such as housekeeping. Conclusion There is a need for more focused education to support registered and non‐registered care home staff to effectively engage in sensitive discussions about death and dying with residents. Furthermore, greater emotional support is necessary to help build workforce resilience and sustain change. Impact Knowledge generated from this study can be used to inform the design and development of future advance care planning interventions capable of supporting the delivery of high‐quality end‐of‐life care in care homes.
Article
Objective: To evaluate the effect of advance care planning (ACP) interventions on the hospitalization of nursing home residents. Design: Systematic review and meta-analysis. Setting and participants: Nursing homes and nursing home residents. Methods: A literature search was systematically conducted in 6 electronic databases (Embase, Ovid MEDLINE, Cochrane Library, CINAHL, AgeLine, and the Psychology & Behavioral Sciences Collection), in addition to hand searches and reference list checking; the articles retrieved were those published from 1990 to November 2021. The eligible studies were randomized controlled trials, controlled trials, and pre-post intervention studies describing original data on the effect of ACP on hospitalization of nursing home residents; these studies had to be written in English. Two independent reviewers appraised the quality of the studies and extracted the relevant data using the Joanna Briggs Institute abstraction form and critical appraisal tools. A study protocol was registered in PROSPERO (CRD42022301648). Results: The initial search yielded 744 studies. Nine studies involving a total of 57,180 residents were included in the review. The findings showed that the ACP reduced the likelihood of hospitalization [relative risk (RR) 0.54, 95% CI 0.47-0.63; I2 = 0%)], it had no effect on emergency department (ED) visits (RR 0.60, 95% CI 0.31-1.42; I2 = 99), hospice enrollment (RR 0.98, 95% CI 0.88-1.10; I2 = 0%), mortality (RR 0.83, 95% CI 0.68-1.00; I2 = 4%), and satisfaction with care (standardized mean difference: -0.04, 95% CI -0.14 to -0.06; I2 = 0%). Conclusion and implications: ACP reduced hospitalizations but did not affect the secondary outcomes, namely, ED visits, hospice enrollment, mortality, and satisfaction with care. These findings suggest that policy makers should support the implementation of ACP programs in nursing homes. More robust studies are needed to determine the effects of ACP on ED visits, hospice enrollment, mortality, and satisfaction with care.
Article
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Background: While previous studies showed that oncology nurses were highly inclined to promote advance care planning (ACP), there is a limited study focusing on ACP that concerns the willingness to promote ACP among palliative nurses in Indonesia. This issue needs to be investigated to determine the causative factors so that interventions for nurses can be arranged to improve ACP in Indonesia. Purpose: This study aimed to identify predictors of the willingness to promote ACP among nurses in palliative care settings. Methods: This study used a descriptive-analytical design with a cross-sectional approach. A total of 150 registered nurses with at least one year of experience were purposively recruited. Data were collected using the Indonesian version of the willingness to promote ACP instrument (I-WPACP) with a possible score range of 24 to 120; the higher the score, the higher the willingness to promote ACP. The descriptive statistic, independent t-test, Pearson correlation test, Spearman rank correlation test, and multiple linear regression test were used to analyze the data. Results: The willingness to promote ACP showed a mean score of 84.73±9.36. The score indicates a high willingness to promote ACP. The experience of receiving palliative care education became a related factor as well as the most closely related factor to the willingness to promote ACP in the palliative care settings (β=0.184; p=0.028). Conclusion: The willingness to promote ACP among nurses is high and closely related to their experience of receiving education about palliative care. Education about palliative care and training on ACP needs to be developed so that nurses can discuss ACP with patients and family caregivers.
Article
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Background The ‘Let Me Decide’ Advance Care Planning (LMD-ACP) programme offers a structured approach to End-of-Life (EoL) care planning in long-term care for residents with and without capacity to complete an advance care directive/plan. The programme was implemented in three homes in the South of Ireland, with a view to improving quality of care at end of life. This paper will present an evaluation of the systematic implementation of the LMD-ACP programme in the homes. Methods Focus groups were conducted with 15 Clinical Nurse Managers and two Directors of Nursing where the programme had been implemented. A semi-structured topic guide was used to direct questions that addressed implementation process, challenges implementing advance care planning, advantages/disadvantages and recommendations for the future. Data was analysed using manifest content analysis. Results Five key categories emerged, with 16 corresponding subcategories. These subcategories emerged as a result of 37 codes. Key benefits of the programme included enhancing communication, changing the care culture, promoting preference-based care and avoiding crisis decision making. Establishing capacity among residents and indecision were among the main challenges reported by staff. Discussion A number of recommendations were proposed by participants and included multi-disciplinary team involvement, and a blended approach to education on the topic. According to participants relationships with residents deepened, there was a more open and honest environment with family, end of life care focused more on symptom management, comfort and addressing spiritual care needs as opposed to crisis decision making and family conflict. Conclusion The introduction of the LMD-ACP programme enhanced the delivery of care in the long-term care sites and led to a more open and positive care environment.
Article
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Background: Hospital admissions among patients at the end of life have a significant economic impact. Avoiding unnecessary hospitalisations has the potential for significant cost savings and is often in line with patient preference. Objective: To determine the extent of potentially avoidable hospital admissions among patients admitted to hospital in the last year of life and to cost these accordingly. Design: An observational retrospective case note review with economic impact assessment. Setting: Two large acute hospitals in the North of England, serving contrasting socio-demographic populations. Patients: A total of 483 patients who died within 1 year of admission to hospital. Measurements: Data were collected across a range of clinical, demographic, economic and service use variables and were collected from hospital case notes and routinely collected sources. Palliative medicine consultants identified admissions that were potentially avoidable. Results: Of 483 admissions, 35 were classified as potentially avoidable. Avoiding these admissions and caring for the patients in alternative locations would save the two hospitals £5.9 million per year. Reducing length of stay in all 483 patients by 14% has the potential to save the two hospitals £47.5 million per year; however, this cost would have to be offset against increased community care costs. Limitations: A lack of accurate cost data on alternative care provision in the community limits the accuracy of economic estimates. Conclusions: Reducing length of hospital stay in palliative care patients may offer the potential to achieve higher hospital cost savings than preventing avoidable admissions. Further research is required to determine both the feasibility of reducing length of hospital stay for patients with palliative care needs and the economic impact of doing so.
Conference Paper
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Introduction. End of Life Care (EOLC) is a national health policy initiative in the UK. This project evaluated the implementation of the Gold Standards Framework (GSF) and Liverpool Care Pathway for the Dying (LCP) on EOL for people with dementia in five care settings in Greater Manchester. Methods. Four care homes and one NHS (mental health) ward where the EOLC initiative had been implemented comprised the case study sites representing a range of care environments with purposive voluntary sampling of carers (staff and family) and multi-disciplinary team (MDT) staff (n=200). Baseline and follow up quantitative and qualitative care data were obtained from documentary evidence and economic analysis and the perspectives and experiences of stakeholders, staff and carers from surveys, interviews and focus groups. Results. The GSF and LCP were identified as being able to assist with meeting EOLC needs of older people with dementia in these care settings. Staff experienced high levels of satisfaction and confidence in EOLC. Staff were more confident that dying residents would not be admitted inappropriately to hospital due to advanced care planning agreed with residents, relatives and GPs. A reduction in hospital transfer for EOLC was identified with economic benefits indicative of the potential for reducing admissions. Conclusions. Use of the GSF and LCP promoted good communication with the wider MDT. The important role of health care assistants should not be underestimated in EOLC and joint training on EOL by GPs, MDT members and care home staff could promote joint working, shared trust and confidence.
Article
Background: Due to limited end-of-life discussions and the absence of palliative care, hospitalisations are frequent at the end of life among nursing home residents in Singapore, resulting in high health-care costs. Aim: Our objective was to evaluate the economic impact of Project Care at the End-of-Life for Residents in homes for the Elderly (CARE) programme on nursing home residents compared to usual end-of-life care. DESIGN AND SETTINGS/PARTICIPANTS: Project CARE was introduced in seven nursing homes to provide advance care planning and palliative care for residents identified to be at risk of dying within 1 year. The cases consisted of nursing home residents enrolled in the Project CARE programme for at least 3 months. A historical group of nursing home residents not in any end-of-life care programme was chosen as the matched controls. Cost differences between the two groups were analysed over the last 3 months and final month of life. Results: The final sample comprised 48 Project CARE cases and 197 controls. Compared to the controls, the cases were older with more comorbidities and higher nursing needs. After risk adjustment, Project CARE cases demonstrated per-resident cost savings of SGD$7129 (confidence interval: SGD$4544-SGD$9714) over the last 3 months of life and SGD$3703 (confidence interval: SGD$1848-SGD$5557) over the last month of life (US$1 = SGD$1.3). Conclusion: This study demonstrated substantial savings associated with an end-of-life programme. With a significant proportion of the population in Singapore requiring nursing home care in the near future, these results could assist policymakers and health-care providers in decision-making on allocation of health-care resources.
Article
Background: Advance care planning is the process of discussing and recording patient preferences concerning goals of care for patients who may lose capacity or communication ability in the future. Advance care planning could potentially improve end-of-life care, but the methods/tools used are varied and of uncertain benefit. Outcome measures used in existing studies are highly variable. Aim: To present an overview of studies on the effects of advance care planning and gain insight in the effectiveness of different types of advance care planning. Design: Systematic review. Data sources: We systematically searched PubMed, EMBASE and PsycINFO databases for experimental and observational studies on the effects of advance care planning published in 2000-2012. Results: The search yielded 3571 papers, of which 113 were relevant for this review. For each study, the level of evidence was graded. Most studies were observational (95%), originated from the United States (81%) and were performed in hospitals (49%) or nursing homes (32%). Do-not-resuscitate orders (39%) and written advance directives (34%) were most often studied. Advance care planning was often found to decrease life-sustaining treatment, increase use of hospice and palliative care and prevent hospitalisation. Complex advance care planning interventions seem to increase compliance with patients' end-of-life wishes. Conclusion: The effects of different types of advance care planning have been studied in various settings and populations using different outcome measures. There is evidence that advance care planning positively impacts the quality of end-of-life care. Complex advance care planning interventions may be more effective in meeting patients' preferences than written documents alone. More studies are needed with an experimental design, in different settings, including the community.
Article
Objective To systematically review the efficacy of advance care planning (ACP) interventions in different adult patient populations. Design Systematic review and meta-analyses. Data Sources Medline/PubMed, Cochrane Central Register of Controlled Trials (1966 to September 2013), and reference lists. Study Selection Randomized controlled trials that describe original data on the efficacy of ACP interventions in adult populations and were written in English. Data Extraction and Synthesis Fifty-five studies were identified. Study details were recorded using a predefined data abstraction form. Methodological quality was assessed using the PEDro scale by 2 independent reviewers. Meta-analytic techniques were conducted using a random effects model. Analyses were stratified for type of intervention: ‘advance directives’ and ‘communication.’ Main Outcomes and Measures Primary outcome measures were completion of advance directives and occurrence of end-of-life discussions. Secondary outcomes were concordance between preferences for care and delivered care, knowledge of ACP, end-of-life care preferences, quality of communication, satisfaction with healthcare, decisional conflict, use of healthcare services, and symptoms. Results Interventions focusing on advance directives as well as interventions that also included communication about end-of-life care increased the completion of advance directives and the occurrence of end-of-life care discussions between patients and healthcare professionals. In addition, interventions that also included communication about ACP, improved concordance between preferences for care and delivered care and may improve other outcomes, such as quality of communication. Conclusions ACP interventions increase the completion of advance directives, occurrence of discussions about ACP, concordance between preferences for care and delivered care, and are likely to improve other outcomes for patients and their loved ones in different adult populations. Future studies are necessary to reveal the effective elements of ACP and should focus on the best way to implement structured ACP in standard care.