This study evaluated the economic demands of nutritional interventions during palliative healthcare. From the analysis of related costs, Group B had a median cost 41% lower than Group C (2,904 CZK vs. 4,920 CZK, respectively). After breaking down the cost data into categories (i.e. nutritional supplements, other medical expenses, requested care, and other care), Group B had zero median cost of nutritional supplements when compared to Group C, where the median cost in this category was 1,575 CZK. A similar observation was made for the categories of “other medical expenses” and “requested care”. Therefore, the data suggests a greater healthcare efficiency under a scheme of nutritional interventions, despite the apparently higher costs incurred by Group A.
Regarding the qualitative aspects of the study, the performed interviews with the involved parties revealed that proper nutrition is essential for the patients throughout the different stages of palliative care, as it improves the patients’ physical condition, mood, and overall well-being, thus enhancing their ability to perform daily activities. However, these interventions often imply a restrictive diet for the patients’ that, in turn, causes lack of adherence. Caregivers must thereby invest time and effort in the patients’ care, including the purchase of specialty foods and meal planning. It must be highlighted that the recommended nutritional measures may limit the ability to share or choose meals in convivial events, and that the provision of nutritional care may also require additional time and resources from the healthcare and administrative staff, thus increasing the complexity of palliative care.
The results hereby shown were obtained from an outpatient palliative oncological care in a single cancer center (COC). Thus, the implementation of the suggested economic measures requires due consideration. Unlike inpatient care, outpatient care requires specific conditions based on a regulated system of procedures and related costs [22, 23]. Therefore, some items are not included in outpatient palliative care, such as the number of days spent by the patient in bed (bed-day) or the frequency of outpatient visits over time (usually calculated per month). Thence, this study seeks to improve the transferability of outcomes to other levels of care through a standard report of unit costs, which must consider the difference between outpatient and inpatient care (University Hospital in Hradec Kralove). Before implementing the results of this analysis, it is necessary to compare these cost estimates with a second reference period where nutritional interventions were not reported and it is clear that this data analysis needs to be tested in a larger multicenter study to address the limitations of the present work.
This study addresses the need for an appropriate evaluation of nutritional support interventions for palliative oncological care patients within the framework of good clinical practice and the incurred costs thereby. The duration of the study correlates with the efficiency horizon of a long-term cost-benefit ratio (ICER) analysis [24]. It must be mentioned that data collection was interrupted when appropriate and as dictated by ethical reasons, i.e. significant deterioration of the patient’s condition. However, this measure only allowed a limited estimation on the qualitative contribution of the nutritional interventions, from which quality of life could be assessed. The importance of the performed interviews should be underscored, as they enabled a wider view on the acquired benefits of nutritional interventions in palliative care patients, e.g. improved physical condition, mood, and overall well-being. In juxtaposition, identifying the drawbacks of these nutritional measures and the economic burden they may pose was rather challenging, as they include dietary restrictions and lack of adherence to its regimen. These and other problems were successfully solved through educational sessions for the palliative care team, clearly illustrating alternatives for nutritional intervention unavailability and palliative care planning.
Alternative treatment.
According to the first-hand experience acquired in our outpatient practice, nutritional interventions for palliative oncological care patients are essential [18], relying heavily on proper timing for initiation and implementation method. From an administrative point of view, the organization and continuity of palliative care is focused on cost-benefit, paying special attention on other services that directly or indirectly affect these nutritional interventions [25]. The analysis hereby shown has the necessary information for decision-makers when concerning the administration of nutritional interventions and the conditions under which they should be provided, and by that we mean both its economic demands and accessibility. In outpatient palliative oncological care, the decision to start and end nutritional interventions is widely discussed from medical, social, and economical standpoints. It is not surprising, then, that a well-functioning and multidisciplinary cooperation within the palliative team has well-defined rules. Further, and in our experience, the main problem in this regard is instead related to the risk of polypharmacy and non-compliance [19]. Considering that outpatient care is often provided at home, the risks of non-compliance, limited communication, care availability, and familial relations are multiplied [26]. These issues may be assuaged if the proper information is supplied to the decision-makers, which in the Czech Republic are represented by health insurance companies.
The economic evaluation of nutritional interventions made in this study is consistent with that of similar reports [27, 28], using a combination of enteral and parenteral nutrition as documented in previous studies [29, 30]. The proper timing for the initiation of nutritional interventions and following palliative steps appear to indeed improve the quality of life of cancer patients; therefore, it should be made available and unburdened by economic limitations.
Impact of the study.
The results hereby shown enable the palliative care team to prepare a tailor-made care plan for the patient i.e. personalized approach. On this basis, the approval rate of nutritional interventions by the appropriate authority (i.e. health insurance company) will increase significantly, thus maintaining the quality, availability, continuity, and economic efficiency of palliative healthcare.
Challenges for health care providers.
The administration of good healthcare is limited, to some degree, by the uncertainty of decision-makers. Said event is often conditioned by the ability to cover the provided care, i.e. nutritional intervention, which is often funded by the patient’s mandatory contributions to the healthcare system. The decision on whether an intervention is administrated or not is based on a cost-effectiveness ratio analysis (ICERs, by its Czech acronym).
The cost-benefit and efficacy analysis performed in this study demonstrate the balanced cost-effectiveness of nutritional interventions. However, the mandatory participation of the patient in healthcare financing may still represent an unavoidable issue. Therefore, the patient’s capacity for co-payment of the incurred costs is often deficient and may lead to the rejection of the proposed nutritional intervention (financial non-compliance). The main factor in this regard comes from the difference between the lump sum reimbursement guaranteed by the health insurance company and the surcharge required by the pharmacy, which increased by 2–5% above the flat rate during the follow-up in our study. It must be mentioned that the increased monthly costs for the patient exceeded 1,240 CZK, thus playing a significant role in the sustainment of nutritional interventions and the risks of non-compliance. This phenomenon also reflects a considerable degree of uncertainty for an economist, further complicated by the relatively small number of patients undergoing nutritional interventions in our and other studies [31, 32]. Despite the positive results of ICER, we are faced with the decision on whether to implement these interventions based on ensuring compliance [33].
Future research.
The observations made will be used to improve and develop optimal procedures and recommendations for nutritional interventions (sipping) in palliative oncology care. Therefore, we plan to expand the size of the group as part of a prospective study focused on nutritional support, compliance, and quality of life to extend a personalized cost-benefit approach to palliative healthcare.