Economic evaluations in the palliative and end-of-life care settings: A systematic review of existing evidence, methods and quality.

Abstract

Rising need for palliative and end-of-life care requires reliable cost-effectiveness evidence to support optimal resource allocation. Relevant value propositions and the applicability of conventional economic evaluation methods, however, may differ from other healthcare fields. To synthesise and critically appraise context-specific economic evaluations with comprehensive methodological and quality lenses including decision-making aspects. We conducted a systematic review of published palliative and end-of-life economic evaluations following a registered, peer-reviewed protocol (CRD42020148160). Cost-effectiveness results, methods, reporting quality (CHEERS), study quality (CHEC) and decision-making contexts were summarised narratively. The databases EMBASE, HTA-Database, MEDLINE, and NHS-EE-Database were searched between 2010 and 2024. Of the 4190 identified references, 46 studies were included. Overall, 59% of the studies stemmed from four countries (UK, Canada, the Netherlands, USA), 54% were trial-based economic evaluations, 59% investigated cancer-related interventions, 41% were conducted in hospital settings, 63% were cost-utility analyses with 83% using EQ-5D for QALY-calculations. Studies typically took a health (and social) care perspective (63%) with 58% corresponding to national health technology assessment decision-making requirements. Of the evaluated interventions, 51% were cost-effective. Reporting quality (52%-96%) and study quality (56%-94%) greatly varied. Economic evaluations in palliative and end-of-life care settings mainly adhered to commonly required decision-making frameworks. This may result in sub-optimal analytical perspectives leading to important missed consequences, omitted alternative value considerations, and ignorance of some existing context-specific methodological recommendations. Developing and promoting consensus-based, context-specific methodological recommendations would be crucial to enhance the appropriateness of economic evaluation evidence in this context.