Palliative care: The holy grail of healthcare interventions?

Interventions that simultaneously improve health outcomes and reduce healthcare costs are the “holy grail” of healthcare delivery. Yet, purveyors of healthcare interventions, including public health prevention and treatment programs, medicines, medical devices, and procedures, frequently claim that their interventions save money. And there is good reason for doing so. With healthcare budgets increasingly constrained, even highly cost-effective interventions, meaning those that improve health at costs that represent good value for money, may not be implemented.

Despite these claims, the reality is that very few healthcare interventions are truly cost-saving. Most improve health, but at an additional cost. Interventions supported by strong evidence of cost savings are largely limited to childhood immunization, tobacco taxation and cessation programs, selected infection-prevention initiatives, generic substitution, and kidney transplantation for patients with end-stage kidney disease.^{1 –5} Even these examples, however, are not without controversy. For example, some have argued that smoking reduces lifetime public expenditures because smokers die earlier and contribute substantial tobacco tax revenues that offset smoking-related healthcare costs. ⁶ Moreover, claims of cost savings are highly dependent on the comparator. Generic medicines may be cost-saving relative to branded medicines with similar efficacy but are unlikely to be cost-saving relative to no treatment. The same holds for kidney transplantation, which is generally cost-saving relative to long-term dialysis, but not relative to conservative non-dialysis management. ⁵

The palliative care community has similarly embraced the possibility that increased access to palliative care saves money. This shift was catalyzed in part by a seminal study by Temel et al., which demonstrated that early integrated palliative care among patients with metastatic lung cancer improved quality of life, was associated with longer survival, and, importantly, reduced aggressive end-of-life care. ⁷ It was this latter finding that led many to claim that palliative care might simultaneously improve outcomes while reducing healthcare expenditures. However, these claims are problematic on several levels.

The first problem is definitional. Despite working in the field for 15 years, I continue to observe substantial ambiguity regarding what constitutes palliative care. This ambiguity is reinforced by varying definitions of the concept itself. The World Health Organization defines palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification, impeccable assessment and treatment of pain and other problems – physical, psychosocial, and spiritual.” ⁸ No doubt this definition was carefully constructed, but it leaves considerable room for interpretation. Indeed, it seems difficult to distinguish this definition from the broader concept of patient-centered medicine that all clinicians should strive to provide. Regardless, it is difficult to imagine how such an approach would consistently generate cost savings, nor should that be the expectation.

As with generic medicines and transplantation, the second problem concerns the comparator. If palliative care saves money, the question is: relative to what? The Lancet Commission on the Value of Death notes that “while many people are overtreated in hospitals with families and communities relegated to the margins, still more remain undertreated, dying of preventable conditions and without access to basic pain relief.” ⁹ In the latter settings, which encompass most of the world’s population, usual care may consist of dying at home with little access to formal medical care. In such contexts, provision of the Essential Package of Palliative Care and Pain Relief is likely to substantially reduce suffering, but at a relatively modest cost of roughly US$3 per capita annually. ¹⁰ This is very good value for money, but not cost-saving.

In developed countries where specialist palliative care is widely available, such services are also likely to improve the end-of-life experience for patients and families, although their ability to generate cost savings is also uncertain. This is partly because referral to specialist palliative care often occurs late in the disease trajectory, typically after life-extending treatments, including potentially non-beneficial treatments, have already ceased. As evidence, the interval between referral and death is often only a few weeks, limiting the opportunity for meaningful reductions in healthcare utilization and costs. ¹¹ Yet, as suggested by Temel et al., it is precisely within these highly medicalized settings where early integration of palliative care may have the greatest potential to both improve health outcomes and reduce costs. But what does the evidence show?

Since the Temel study, numerous investigations have attempted to test the hypothesis that access to palliative care, in any setting and initiated at varying points in the disease trajectory, saves money. A recent systematic review published in this journal summarized the evidence. ¹² The review identified 46 relevant studies, the majority originating from the United Kingdom, United States, Canada, and the Netherlands, with most focusing on patients with cancer. Most evaluations were trial-based studies of hospital- or home-based interventions conducted in high-income settings. Importantly, no studies from low- or lower-middle-income countries were included. Of the 73 individual comparisons included in the review, 32% reported cost savings, 19% were cost-effective but not cost-saving, 28% were either not effective or not cost-effective, and the remainder did not provide interpretable evidence. In a more recent study, May et al. modeled the cost-effectiveness of home- and hospital-based specialist palliative care for adults with poor prognosis in England. ¹³ They concluded that both home- and hospital-based specialist palliative care were cost-saving, largely through reductions in hospital bed days. These findings, while suggestive, should be interpreted cautiously. In their systematic review, the authors highlighted substantial methodological shortcomings across many studies that “challenge the validity and reliability of the results,” including omission of important costs and poor definition of comparators. They further noted that only 20% of studies adhered to established reporting guidelines for economic evaluations.

I do not dispute the conclusion of the review that some palliative care interventions are, on average, cost-saving in some settings. However, I agree with the authors’ broader conclusion that substantial heterogeneity across settings limits generalizability. May et al. raise a similar concern, arguing that their results may not generalize even across patients within the same setting. They note that intervention costs, patient preferences, treatment patterns, and outcomes vary across patients according to numerous factors not captured in their model. This is why they conclude that their study “should be the start and not the end of decision models that identify how and for whom specialist palliative care makes the biggest difference.” ¹³

So where does this leave us? My sense, based on both the nature of palliative care delivery and the available evidence, is that cost savings from palliative care interventions are more likely the exception than the rule. But cost savings should not be the benchmark by which palliative care is judged. Palliative care, using any reasonable definition, provides good value for money because of its relatively low cost and its ability to improve the experiences of patients and families near the end of life. While this may not be sufficient to convince all payers, I would urge caution when making broader claims of cost savings for two reasons. First, if such savings fail to materialize in practice, payers may become even less willing to support these interventions in the future, regardless of the evidence. Second, by requiring palliative care to save money, we risk holding it to a higher standard than nearly every other healthcare intervention. Palliative care should not be held to a standard that very few healthcare interventions achieve. Its value lies in its ability to cost-effectively alleviate suffering and improve the experiences of patients and families at very low cost. That is the case we should be making to payers and policymakers.