Pediatric palliative care and end-of-life: a systematic review of economic health analyses

Lo, Denise Swei; Hein, Noely; Bulgareli, Jaqueline Vilela

doi:10.1590/1984-0462/2022/40/2021002

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Revista Paulista de Pediatria

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Review Article • Rev. paul. pediatr. 40 • 2022 • https://doi.org/10.1590/1984-0462/2022/40/2021002 copy

Pediatric palliative care and end-of-life: a systematic review of economic health analyses

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To perform a systematic review of the health economic evidence on the care of children and adolescents with complex clinical conditions, comparing groups included and not included (control group) in palliative care at the end of life.

Data source:

The seven databases searched were PubMed, Embase, Web of Science, Cochrane Library, Virtual Health Library–Latin American and Caribbean Health Sciences Literature (VHL-LILACS), EBSCOhost, and Paediatric Economic Database Evaluation, following recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement, from January 1979 to November 2020. The review included studies of patients under 18 years of age with complex clinical conditions that compared a palliative care group with a control group. The economic outcomes analyzed were length and place of stay at the end of life (home, hospice, ward, intensive care unit, emergency room), diagnostic and therapeutic procedures performed, and health-related costs. The exclusion criteria were: studies without a matched control group, conference/congress abstracts, letters to the editor, editorials, comments, qualitative studies, narrative reviews, studies with ten or fewer participants in each group, articles published in languages other than English, Portuguese, or Spanish.

Data synthesis:

Out of the 518 articles identified, 4 met the inclusion criteria. We found evidence of direct economic benefits, such as reduced health costs, indirect savings, and protection of patients from undergoing invasive procedures, surgeries, and costly therapies, which cause greater suffering at the end of life. Therefore, participating in a palliative care program saved financial and technological resources, besides increasing the frequency of deaths at home and improving the quality of life.

Conclusions:

Public and private policies to promote palliative care represent better efficiency when allocating available health care resources.

Keywords:
Systematic review; Palliative care; Hospice care; Health economics; Pediatrics

Main author	Study period	Country	Case description	Age (years)	Method	Patients (n)		Outcome description
Main author	Study period	Country	Case description	Age (years)	Method	Palliative care	Control group	Outcome description
Smith et al.¹⁶16. Smith AG, Andrews S, Bratton SL, Sheetz J, Feudtner C, Zhong W, et al. Pediatric palliative care and inpatient hospital costs: a longitudinal cohort study. Pediatrics. 2015;135:694-700. https://doi.org/10.1542/peds.2014-3161 https://doi.org/10.1542/peds.2014-3161...	2010 to 2012	United States of America	The 10% most costly inpatients in 2010	0–18	Retrospective cohort	86	816	Comparison between groups regarding costs and days of hospitalization, daily cost per patient, daily costs before and after inclusion in palliative care programs.
Chong et al.¹⁷17. Chong PH, Castro Molina JA, Teo K, Tan WS. Paediatric palliative care improves patient outcomes and reduces healthcare costs: evaluation of a home-based program. BMC Palliat Care. 2018;17:1-8. https://doi.org/10.1186/s12904-017-0267-z https://doi.org/10.1186/s12904-017-0267-...	2012 to 2015	Singapore	Children and adolescents with complex clinical conditions (more than 40% with neoplasms)	0–18	Retrospective case-control	71	67	Evaluation of the number and length of hospitalizations, visits to the emergency department, and medical expenses in the last year of life
Keele et al.¹⁸18. Keele L, Keenan HT, Sheetz J, Bratton SL. Differences in characteristics of dying children who receive and do not receive palliative care. Pediatrics. 2013;132:72-8. https://doi.org/10.1542/peds.2013-0470 https://doi.org/10.1542/peds.2013-0470...	2001 to 2011	United States of America	Deaths recorded in the Pediatric Health Information System database, with at least five days of hospitalization	0–18	Retrospective cohort	919	23,423	Evaluation of the median days of hospitalization, number of invasive procedures, stay in the intensive care unit, and hospital expenses
Pierucci et al.¹⁹19. Pierucci RL, Kirby RS, Leuthner SR. End-of-life care for neonates and infants: The experience and effects of a palliative care consultation service. Pediatrics. 2001;108:653-60. https://doi.org/10.1542/peds.108.3.653 https://doi.org/10.1542/peds.108.3.653...	1994 to 1997	United States of America	Deaths of children admitted to a tertiary hospital	0–1	Retrospective case-control	25	123	Assessment of the place of death and medical procedures performed

Main author	Outcome summary	Description of the main results
Smith et al.¹⁶16. Smith AG, Andrews S, Bratton SL, Sheetz J, Feudtner C, Zhong W, et al. Pediatric palliative care and inpatient hospital costs: a longitudinal cohort study. Pediatrics. 2015;135:694-700. https://doi.org/10.1542/peds.2014-3161 https://doi.org/10.1542/peds.2014-3161...	The group that received palliative care had lower hospital expenses in the two years before death, while the survivors of this group had higher expenses. When adjusted for disease complexity, expenses were similar.	The palliative care group had more complex diseases. Economic results varied according to survival time. Hospitalization costs of patients who received palliative care and died in the following two years were lower than those of the control group, with no significant difference in the daily cost of hospitalization and admission to pediatric intensive care. Inclusion in the palliative care program reduced the mean daily cost from US$ 4,732 to US$ 3,625 (p<0.001).
Chong et al.¹⁷17. Chong PH, Castro Molina JA, Teo K, Tan WS. Paediatric palliative care improves patient outcomes and reduces healthcare costs: evaluation of a home-based program. BMC Palliat Care. 2018;17:1-8. https://doi.org/10.1186/s12904-017-0267-z https://doi.org/10.1186/s12904-017-0267-...	Comparison between the palliative care group and the control group showed a significant decrease in hospitalizations and medical costs in the last year of life, particularly in the last month.	In the last year of life, compared to controls, patients in the palliative care group stayed more days at home than in hospital (OR 52.3; 95%CI 25.44−79.17), and 70% had lower medical expenses. Costs in the last month of life decreased by 87% in the palliative care group. The mean age in years of the palliative care group was significantly higher than that of controls (12.2 vs. 6.3). The quality of life of patients and family members improved after inclusion in the palliative care program.
Keele et al.¹⁸18. Keele L, Keenan HT, Sheetz J, Bratton SL. Differences in characteristics of dying children who receive and do not receive palliative care. Pediatrics. 2013;132:72-8. https://doi.org/10.1542/peds.2013-0470 https://doi.org/10.1542/peds.2013-0470...	The palliative care group had a higher median age and different complex clinical conditions than the control group. Comparison between the groups revealed fewer days of hospitalization, fewer invasive procedures, fewer deaths in the intensive care unit, and lower hospital expenses in the palliative care group.	The group receiving palliative care had lower median days of hospitalization than the control group (17 vs. 21), as well as reduced daily costs (US$ 9,348 vs. US$ 11,806), underwent fewer invasive procedures, and presented fewer deaths in the intensive care unit (60 vs. 80%). A significant difference was found concerning the higher age of the palliative care group. Children under 30 days of life corresponded to 41% of deaths, and only 2% of them received palliative care.
Pierucci et al.¹⁹19. Pierucci RL, Kirby RS, Leuthner SR. End-of-life care for neonates and infants: The experience and effects of a palliative care consultation service. Pediatrics. 2001;108:653-60. https://doi.org/10.1542/peds.108.3.653 https://doi.org/10.1542/peds.108.3.653...	Infants who received palliative care were submitted to fewer diagnostic and therapeutic procedures and stayed fewer days in the intensive care unit than the control group.	Infants in palliative care showed significant reductions compared to controls, with a lower infusion of blood products (36 vs. 63%), central line insertion (64 vs. 92%), endotracheal intubation (60 vs. 94%), use of feeding tubes (64 vs. 95%), and X-ray examinations (40 vs. 89%). A significant difference was identified in the last 48 hours of life, with 44% of infants in the palliative care group without blood tests versus 7% in the control group. The use of vasopressors was limited to 56% of the palliative care group against 13% of the control group.

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[1] *Corresponding author. E-mail: deswlo27@gmail.com (D. S. Lo).