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Expert Review of Pharmacoeconomics & Outcomes
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Drug utilization and medication costs at the end of
life
Lisa Pont, Kristian Jansen, Margrete Aase Schaufel, Dagny Faksvåg Haugen &
Sabine Ruths
To cite this article: Lisa Pont, Kristian Jansen, Margrete Aase Schaufel, Dagny Faksvåg
Haugen & Sabine Ruths (2016) Drug utilization and medication costs at the end of
life, Expert Review of Pharmacoeconomics & Outcomes Research, 16:2, 237-243, DOI:
10.1586/14737167.2016.1158106
To link to this article: http://dx.doi.org/10.1586/14737167.2016.1158106
Accepted author version posted online: 26
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Published online: 25 Mar 2016.
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Date: 12 April 2016, At: 01:07
EXPERT REVIEW OF PHARMACOECONOMICS & OUTCOMES RESEARCH, 2016
VOL. 16, NO. 2, 237–243
http://dx.doi.org/10.1586/14737167.2016.1158106
REVIEW
Drug utilization and medication costs at the end of life
Lisa Ponta, Kristian Jansenb,c, Margrete Aase Schaufelb,d, Dagny Faksvåg Haugene,f and Sabine Ruthsb,c
Downloaded by [University of Technology Sydney] at 01:07 12 April 2016
a
Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia; bResearch
Unit for General Practice, Uni Research Health, University of Bergen, Bergen, Norway; cDepartment of Global Public Health and Primary Care,
University of Bergen, Bergen, Norway; dDepartment of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway; eRegional Centre of
Excellence for Palliative Care, Haukeland University Hospital, Bergen, Norway; fDepartment of Clinical Medicine, University of Bergen, Bergen,
Norway
ABSTRACT
ARTICLE HISTORY
In the end stages of life, drug treatment goals shift to symptom control and quality of life and as such
changes in drug utilization are expected. The aim of this paper is to review the extent to which costs are
considered in drug utilization research at the end of life, with a particular focus on the outcome
measures being used. This systematic review identified seven studies across varied settings studies
reporting both drug utilization and medication cost outcome measures. The main factors identified that
impacted medication use and cost were the time period considered and the provision of specialist
palliative care services. Combining drug utilization and medication cost outcomes is critical for the
allocation of healthcare resources and the development of a sound health policy.
Received 12 January 2016
Accepted 22 February 2016
Introduction
Increasing expenditure on medications represents an ongoing
challenge to many health systems [1]. The U.S. annual expenditure on medications was estimated at over $440 billion in
the year 2015 and is expected to reach over $700 billion by
2020 [2]. Understanding current patterns in medication use
and the related impact on medication expenditure is critical
for allocation of health care resources and development of
sustainable health policy. Drug utilization research provides
insight into the way medications are used within society, with
emphasis on the medical, social and economic consequences
[3]. Drug utilization research is currently used to assess quality
use of medicines, to identify areas of suboptimal medication
use, to provide feedback to prescribers and to benchmark
medication use within and between settings [4].
Internationally, there is a focus on the provision of quality
medical care throughout the entire continuum of life, including at the end of life. It is generally acknowledged that medical management at the end of life should focus on optimizing
quality of life and minimizing symptoms, rather than on
extending the duration of life [5]. Such a shift in treatment
goals from preventative and curative care to symptomatic care
will impact the drug therapy used during the end-of-life period, requiring changes to the types, formulations, administration routes and doses of medications used. Specialized
palliative care services may oversee such changes for those
patients referred to their care; however, limitations in access to
palliative care services mean that end-of-life care for many
patients is managed outside of these specialized services.
Drug utilization research into the use of medications at the
end of life has shown increases in the use of medicines for
CONTACT Lisa Pont
[email protected]
© 2016 Informa UK Limited, trading as Taylor & Francis Group
KEYWORDS
End-of-life; drug utilization;
systematic review; palliative
care; medication costs
symptom control [6], yet little is known about the impact
these changes have on medication utilization and medication-related expenditure. Inclusion of cost-related outcomes
in drug utilization studies would allow insight into the relationship between medication utilization and medication
expenditure at the end of life. However, it is unknown to
what extent drug utilization research at the end of life includes
cost outcomes and which drug utilization and medication
cost-related outcomes are currently used when studying this
population. Therefore, the aim of this study was to review the
extent to which costs are considered in end-of-life drug utilization research, with a particular focus on the medications
included and the utilization and cost outcome measures used.
Methods
A systematic review following the preferred reporting items for
systematic reviews and meta-analyses statement was conducted
across six electronic databases using a search strategy modified
from that published in the National Institute of Clinical
Excellence (NICE) guidance: Care of the dying adult [7].
Medline, Embase, Cochrane central register of controlled trials,
Cochrane database of systematic reviews, CINAHL (Cumulative
Index to Nursing and Allied Health Literature) and PsycINFO
were searched using a combination of the terms ‘death’, ‘terminally ill’, ‘palliative care’, ‘hospice care’, ‘end-of-life’, ‘drug therapy’
and ‘cost’. The full search strategy is available in Appendix 1.
Studies were included in the review if they focused on endof-life care, reported both drug utilization and medication cost
outcomes, were written in English, and to increase relevance
for current practice, were published in the past 20 years, that
is, between 1995 and 2015. Conference abstracts, case reports,
238
L. PONT ET AL.
opinion pieces and editorials and clinical treatment guidelines
were excluded from the review.
Data were extracted from full text papers by a single
researcher (Lisa Pont) using a standardized data extraction
form. The data extracted included study characteristics
(country, year, population, aim and sample size),
drug utilization measures (drug agents or class and drug
utilization outcome measure) and medication cost
outcome.
Identification
The search strategy identified 410 studies (Figure 1), of which
seven met the inclusion criteria and were included in this
review (Table 1) [8–14]. While the studies were conducted
across a variety of countries, the highest number of the
included studies were conducted in Europe (n = 3). While all
of the included studies reported drug utilization and medication
cost-related outcomes, the aims of the studies were diverse.
Only one study aimed to examine drug utilization and related
costs at the end of life [8]. Fahlman et al. found that medication
costs at the end of life varied depending on the cause of death.
Medline
Embase
(n = 50)
(n = 382)
Cochrane
trials
(n = 1)
CINAHL
Psychinfo
(n = 20)
(n = 15)
Eligibility
Screening
Records after duplicates removed
(n = 410)
Included
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Results
Patients with chronic obstructive pulmonary disease and diabetes had the highest medication utilization and costs prior to
death. However, this study reported only aggregated medication costs and did not provide information on utilization or
costs associated with individual medications or classes.
Most studies (n = 6) were conducted retrospectively
[8,9,11–14]. Only the Finnish study examining the quality of
pain control at the end of life was conducted prospectively
[10]. This was a small observational study with 36 participants,
focused on the last 2 weeks of life. Despite all studies focusing
on the end-of-life period, there was great diversity in the time
before death that was considered ‘end of life’. Tavčar et al.
examined drug utilization over the last 6 days of life, Hinkka
et al. examined the last week and last 24 hours, Silvera et al.
and Gaertner et al. examined the last 6 months and Fahlman
et al. reported on use during both the last month of life and
the last year of life.
The importance of including time or proximity to death in
drug utilization studies was highlighted by Moore, Bennet and
Norman [12]. In a retrospective case–control study using
National data from the New Zealand Ministry of health pharmacy claims for over 40,000 older residents, they showed that
Figure 1. Search and study selection.
Records screened for title
and abstract
(n = 410)
Records excluded after title and
abstract screening
(n = 366)
Full-text articles assessed
for eligibility
(n = 44)
Full-text articles excluded,
(n = 37)
No medication cost data (n=18)
No drug utilization data (n=12)
Not end of life (n=2)
Case study (n=1)
Editorial, opinion piece or
treatment guideline (n=4)
Studies included in
qualitative synthesis
(n = 7)
1998–
2000/US$
2013/€
2001€
2013 US$
2014NZ$
2008US$
2014€
Fahlman et al. [8]
(USA)
Gaertner [9]
(Germany)
Hinkka [10] (Finland)
Hwang [11] (Taiwan)
Moore [12] (New
Zealand)
Silvera [13] (USA)
Tavčar et al. [14]
(Slovenia)
BARMER GEK Health
insurance beneficiaries/
claims data
Medicare beneficiaries/
claims data
Population/data type
11,355
4602
Patients with a life-limiting 1584
illness receiving care at
Veterans Integrated
Service Network facilities
using a statin/pharmacy
supply data
To identify differences in use Patients with incurable
50
of drugs among terminally
advanced cancer who
ill patients receiving
died at the Institute of
palliative care versus
Oncology/inpatient
standard care
medical records
To measure the prevalence
of statin use during the
last 6 months of life
To assess the quality of
Patients admitted with
36
cancer pain control during
terminal cancer during
the last week of life in two
1998/inpatient medical
different types of units for
records
terminal cancer patients in
Finland
To compare the
National health insurance 3236
characteristics of patients,
beneficiaries with cancer
medical procedures,
who died during the
prescriptions and
study period/claims data
expenses between
hospice and usual care
To examine the effect of age Residents aged 70 years
40,322
and proximity to death on
and older present in the
medication use and cost
New Zealand Ministry of
Health Pharmacy claims
data/pharmacy supply
data
Effect of palliative care on
patient care during last 6
months of life
To examine drug spending
by disease and
demographics in the last
year of life
Aim
Sample
size
Retrospective case
control
6 days
6 months
12 months
Retrospective case
control
Retrospective case
control
Not stated
1 week
6 months
12 months
End-of-life period
(time prior to death)
Retrospective
observational
Prospective
observational
Retrospective case
control
Retrospective
observational
Study design
Some comparative data are presented for nervous system medications, but total use for each group is not presented.
§
Year/currency
Author (country)
Table 1. Study characteristics and summary of findings.
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Top seven most
frequently
prescribed
drug classes
Number of
participants
prescribed
each
medication
class Number
of drugs per
person
Mean number of
prescriptions
filled
Drug utilization
outcome
Medication cost
outcome
Cost for drugs over 6
days
Average cost for
drugs per person
per day
Mean out-of-pocket
cost
Mean amount paid
by insurer
Mean amount
claimed by
pharmacy
Opioids
The proportion of Total inpatient
patients who
medication costs
received at
least one
dosage of
opioids
The mean
defined daily
dose (DDD) of
opioids
Opioids
DDDs of pain
Cost of daily pain
medications
medication 7 days
Proportion of
and 24 h prior to
patients
death
receiving
strong opioids
Top 10
Percentage of
Mean cost per
medication
patients
patient per day
classes used in
prescribed
each setting
each
medication
class
Number of items Expenditure per
Not specified§
per individual
individual
Total annual
expenditure
Median
expenditure per
individual
Average
expenditure per
prescriptions
Statins
Number of days Total cost of statin
of statin use
therapy
prior to death
Not specified
Pharmacological
agent and/or
class
EXPERT REVIEW OF PHARMACOECONOMICS & OUTCOMES RESEARCH
239
240
L. PONT ET AL.
drug utilization and expenditure vary in the last month of life
depending on age. Patients in their last month of life used
almost twice as much medication as age-matched survivors.
However, while expenditure among controls increased with
age, expenditure for those in the last month of life decreased
with age. Hinkka et al. observed and reported that medication
expenditure for daily pain medication increased in the last
week of life [10].
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Medications included
There was variation in the medications included in each of
the studies. Opioids were the focus of two studies, the small
(n = 36) prospective Finnish study [10] and the much larger
(n = 11,355) German study [9]. Despite difference in sample
size and design, both studies reported similar finding that
patients receiving specialist palliative care services were
more likely to receive opioids than those receiving standard
care and that the doses of opioids received were 2–4 times
higher in palliative care than in standard care. Hinkka et al.
also showed differences in the choice of opioids, with standard care patients receiving parenteral morphine earlier
than those with palliative care (percentage of users at 1
week prior to death 20 vs. 0%, p = 0.021).
One study focused on the use of statins at the end of life
[13], and two explored overall drug utilization [11,14], generally reporting the most frequently prescribed medications. In
both papers, looking at most frequently used medications,
opioids were the most commonly used agent followed by
laxatives in the Slovakian paper [14] and electrolyte fluids in
the Taiwanese paper [11].
Drug utilization outcomes
The data sources used in the different studies impact on the
aspect of drug utilization measured. Three studies used health
insurance claims data. Claims data provide information on
medications received by a patient that were funded by a
specified third-party payer [8,9,11]. Two studies used medication data recorded in patient hospital medical records [10,14],
while two studies used pharmacy medication supply data
[12,13].
Three main drug utilization outcome measures were
reported in the studies. Three studies[9–11] reported on the
number or percentage of patients who received each medication or drug class, three studies[8,12,14] reported the number of medications or items per patient, and two studies
[9,10] reported the mean defined daily dose [3,15] (DDD)
per patient. Three studies [9,10,14] used multiple drug utilization measures, in two cases a combination of the proportion of patients receiving a medication and the DDDs being
used and in one case a combination of the proportion receiving the medication and the number of medications per
patient. Interestingly, the two studies that reported DDDs
as a drug utilization outcome measure were both focused
on the use of opioids.
Medication cost-related outcomes
There was variation in the medication cost outcome measures
reported. While total medication cost per patient was the most
commonly used outcome measure, different studies focused
on cost from different perspectives. Gaertner et al. reported
total inpatient pharmacy costs but did not clarify if these were
only medication-related costs or if they included other costs
such as pharmacy labor as well [9]. This study was also unable
to include outpatient or ambulatory medication costs, as these
were not captured in the health insurance data set used for
their analysis. Hwang et al., Moore, and Tavčar et al. reported
cost per patient but did not indicate what was included in
these costs [11,12,14]. Fahlman et al. reported costs from a
third-party payer perspective using mean out-of-pocket costs,
mean cost to the insurer and mean amount claimed by the
pharmacy [8].
Factors affecting drug utilization and expenditure
The type of care provided was shown to have a significant
impact on both drug utilization and related medication costs.
Four studies examined differences in the provision of specialist
palliative care at the end of life versus usual care [9–11,14]. All
four studies used retrospective designs and reported differences in drug utilization and medication costs between the
types of care provided. Care issued by specialist palliative care
providers or settings was associated with lower medication
costs. There were distinct differences observed in the types of
medications used between the different care providers. Both
the Taiwanese and the Slovakian studies reported much
higher use of antibiotics and total parenteral nutrition (TPN)
for patients receiving standard care compared to those receiving palliative care, which may account for the increased medication expenditure. In the Taiwanese study, 80% of patients
receiving usual care received TPN and 61% received cephalosporin antibiotics, which may account for the 4× higher medication costs observed with standard care. However, like most
of the studies included in this review, only aggregate drug
costs were provided with drug costs for individual drug classes
not provided.
Discussion
This systematic review explored the extent to which costs are
considered in end-of-life drug utilization research, with a particular focus on the outcome measures being used. Seven
studies published in the past two decades were identified
that reported both drug utilization outcomes and medication-related cost outcomes. While all studies considered medication use among end-of-life populations, there was
considerable variation in the drug utilization and cost-related
outcomes used, as well as in the period considered the end of
life.
Drug utilization research has traditionally utilized a range of
outcome measures. There is a need for different outcome
measures, which depend upon the question being researched
[3]. Such diversity, however, makes comparing between
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EXPERT REVIEW OF PHARMACOECONOMICS & OUTCOMES RESEARCH
studies challenging. In our review, three main drug utilization
outcome measures were used: proportion of the population
using a particular medication, the dose measured in DDDs of
the medication being used and the number of medications or
items used per person. Each of these provides information
regarding a different aspect of medication use. Proportion of
the population of interest receiving a particular medication
provides information regarding the extent of medication use,
while information on the dose being used, measured through
the World Health standardized DDD methodology [15], allows
interpretation of the amount of medication used at the individual patient level. Both outcome measures, the extent of use
and the amount being used, should be used together to
assess quality of care and allocate resources.
Using information on medication costs in combination with
drug utilization data is important when allocating resources or
developing health policy. A number of medication cost outcomes have been proposed for use with drug utilization data,
and again, the choice of metric will depend upon the purpose
of the analysis. Interpretation of medication-related cost outcomes depends on the perspective from which the costs are
being allocated. Costs may be considered from the perspective of the government, health facility or setting, health care
provider, insurer or other third-party payer or from the patient.
In our review, the majority of studies did not provide adequate
information regarding the perspective from which costs were
determined. The perspective from which costs were being
determined was described in only one study. Fahlman et al.
used a combination of three cost outcome measures measuring cost from three different perspectives: the patient-mean
out-of-pocket costs, the insurer-mean amount paid by the
insurer and the health facility-mean amount claimed by the
pharmacy [8]. The combination of these three measures allows
the full implication of changes in drug utilization to be
assessed across for all relevant payers. Medication costs per
individual was used as an outcome measure in six of the
studies, with three of these looking at medication cost per
individual and three looking at total medication costs.
In this review, two studies focused on the utilization of
opioids used such a combination. The aim of both studies
was to evaluate the impact of specialist palliative care services
[9,10]. While these services are associated with increased total
health care costs, the drug utilization data presented indicates
that patients treated using these services were more likely to
receive opioid analgesics in higher doses, which may equate
differences in the level of pain, improved pain management
and quality of life. Analysis of the medication cost outcomes
shows that despite overall increased health outcomes, medication-related costs are actually lower in specialized palliative
care services when compared to usual care [16,17].
Interpretation of the third drug utilization outcome measure used, number of items or number of prescriptions per
patient, in the end-of-life context is more problematic. While
this outcome measure may facilitate interpretation of expenditure data, allowing insight into the spread of medication use
among a particular population, without accompanying medication cost-related data, such a measure is difficult to interpret. Simply looking at the number of medications used by a
patient does not provide information on the appropriateness
241
of use, and while research has indicated overuse of inappropriate medications at the end of life [13,18,19], simply measuring
the number of medications used does not provide any indication about the need or expected benefit associated with
their use.
Understanding the data source used in drug utilization
studies is an important consideration in interpreting the
results of drug utilization outcomes; yet, these differences
may be less relevant for the interpretation of associated
costs. Drug utilization research encompasses marketing, prescription, supply and use of medications in society, and knowing which aspect of utilization is being considered in a
particular drug utilization study is critical [3]. In studies using
medication supply data, such as claims or dispensing data, it is
known that the patient receives the drug, but it is not known
if they actually utilize it. With the use of prescribing records as
a data source, it is known that the doctor wishes the patient to
use the medication but actual use by the patient is unknown,
while with administration data, actual medication use can be
determined. Generally, such differences in data have considerable implications for interpretation of drug utilization studies;
however, these differences may be less when medication costs
are considered, as it is receipt of the medication by the patient
that becomes the critical factor.
In this review, two factors were found to impact medication
costs and utilization at the end of life. The first was proximity to
death or the length of the time period studied. Moore, Bennet
and Norman showed that proximity to death had a significant
effect on medication expenditure among older communitydwelling people [12]. Medication utilization and expenditure
at the end of life decreased with age, with those who died at the
age of 90 years or older consuming fewer drugs than those who
died in their 70s and 80s. Interestingly, similar decreases have
been shown for medication use by older adults in primary care
who are not at the end of life [20].
Differences in what is considered the end of life are well
documented [21–26]. A study in 2013 of 167 health professionals and academics working in 19 countries found that
there was no agreement regarding what was considered
end-of-life care [21]. In the studies included in our review,
there was great diversity in the time period considered to be
‘end of life’ over which medication utilization and costs were
examined. The time periods included ranged from the last
24 h of life to the last year of life, making comparison of
drug utilization patterns between the studies impossible.
Differences in care services provided, availability of specialized palliative services as well as the reason for death and
comorbid conditions will all contribute to differences in medication utilization during the end-of-life period. Provision of
specialist palliative care was associated with differences in
drug utilization and medication costs. Best practice for endof-life care acknowledges the importance of symptom management and quality of life measures rather than the provision
of active life-prolonging treatment [27]. Provision of specialist
palliative care services has been shown to improve quality of
life, patient and provider satisfaction, and decrease hospitalizations at the end of life [16,17]. Four of the studies included
in our review examined the impact of specialist palliative care
services on medication utilization and medication costs.
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L. PONT ET AL.
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Palliative care services in all four studies were associated with
changes in drug utilization that are consistent with increased
use of symptom-controlling medications and decreased medication expenditure [9–11,14].
One of the main limitations to this systematic review was
the diversity of terminology used to describe the end-of-life
period as discussed previously. To minimize this, we used a
previously published search strategy that was developed by
the U.K. National Institute of Clinical Excellence as part of their
consultation process for their guidance on Care of the dying
adult [7]. Following the public consultation process, the focus
of the guidance document changed to care of the dying adult
in the last few days of life; however, this time limitation was
not reflected in the original search strategy, and hence, the
original search strategy remains relevant to our research question [28].
Conclusion
A variety of drug utilization and medication costs outcomes are
used in end-of-life research; however, the total number of
studies reporting both drug utilization and medication costs
at the end of life was small. While medication cost data provide
insight into total expenditure and may be useful for resource
allocation, changes in drug costs may result from multiple
changes in drug utilization such as changes in the agent, the
amount or the cost of individual items, and use of cost data
alone without the corresponding drug utilization information
may be misleading. Similarly, drug utilization data without the
corresponding cost outcome may be of limited benefit to policy
makers and for resource allocation to end-of-life health care.
Expert commentary & five-year view
The world’s population is aging, and while end-of-life care is not
only relevant for older populations, older persons still account
for the largest population for whom such care is being provided. Demands on resources for end-of-life care will see huge
increases in the coming 5 years. The challenge for clinicians and
policy makers alike is the provision of high quality end-of-life
care in resource-limited environments. Drug utilization studies
provide insight into how medicines are used within society,
while pharmacoeconomic evaluations have tended to focus
on costs associated with individual medicines or conditions.
Consideration of both utilization and expenditure patterns is
needed for development of robust health policy and provision
of quality health care. This review highlights the lack of studies
on medicine use at the end of life integrating both utilization
and cost outcomes. End-of-life research incorporating utilization and cost outcomes is desperately needed to guide future
policy and care in this critical area.
Key Issues
● Changes in medication utilization are expected during endof-life care. Treatment goals shift to minimizing symptoms
and improving quality of life rather than prolonging life.
● Drug utilization studies provide insight into the way medicines are used across society, allowing assessment of the
quality of care as well as providing information to guide
resource allocation and health policy development.
● Robust health policy and provision of quality end-of-life
care require drug utilization and associated medication
cost data, yet little is known regarding the use of medication-related cost outcomes in drug utilization research.
● There are few studies reporting both drug utilization and
related medication cost outcomes at the end of life.
● In the seven studies reporting both end-of-life medication
utilization and cost outcomes, there was variation in the
outcome measures used, making direct comparisons
between the studies difficult.
Financial & competing interests disclosure
L Pont is partially funded by an Australian National Health and Medical
Research Council (NHMRC) Translating Research into Practice Fellowship. The
authors have no other relevant affiliations or financial involvement with any
organization or entity with a financial interest in or financial conflict with the
subject matter or materials discussed in the manuscript apart from those
disclosed.
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(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18)
(19)
(20)
(21)
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Appendix 1 Search strategy
(35)
End-of-life drug therapy and cost review – search strategy in Ovid MEDLINE:
(36)
(37)
(38)
(39)
(1) Death/(12476)
(2) Terminally ill/(5725)
243
Terminal care/or hospice care/(26880)
Palliative care/(43279)
Palliative medicine/(49)
‘Hospice and palliative care nursing’/(150)
(dying or die* or death).ti,kf. (301172)
((terminal or palliati*) adj1 care).ti,kf. (11287)
(‘terminally ill’ or ‘terminal illness’).ti,kf. (2132)
(palliati* adj1 stage*).ti,ab. (359)
(‘end-of-life’ adj2 (stage or stages)).ti,ab. (49)
or/1–11 (364700)
‘end-of-life’.ti,ab. (13908)
((last or final) adj1 (hour* or days* or minute* or stage* or week* or
month*)).ti,ab. (14642)
((dying or terminal) adj1 phase*).ti,ab. (2030)
((dying or terminal or end) adj1 stage*).ti,ab. (51986)
(dying adj2 (actively or begin* or begun)).ti,ab. (53)
(death adj2 (imminent* or impending or near or throes)).ti,ab. (1564)
((dying or death) adj2 (patient* or person* or people)).ti,ab. (20683)
(Body adj2 (shut down or shutting down or deteriorat*)).ti,ab. (115)
(deathbed or death-bed).ti,ab. (98)
or/13–21 (101137)
12 and 22 (19542)
drug therapy/or drug administration routes/or drug administration
schedule/or drug prescriptions/or drug therapy, combination/or fluid
therapy/or home infusion therapy/or inappropriate prescribing/or
medication errors/or polypharmacy/or premedication/or self administration/or self medication/(333170)
drug therapy.fs. (1846732)
exp Analgesics/(455564)
exp anti-anxiety agents/or exp antipsychotic agents/(157583)
exp Benzodiazepines/(60672)
exp Antiemetics/(131824)
exp Cholinergic Antagonists/(75547)
exp Diuretics/(73436)
(analges* or morphin* or opioid* or antiepileptic* or anticonvuls* or
acetaminophen or paracetamol or NSAIDs or non-steroidal antiinflammat*).ti,ab,kf. (237984)
(anti-anxiety agent* or Midazolam or anxiolytic* or diazepam or
oxazepam or lorazepam or benzodiazepine*).ti,ab,kf. (60986)
(anticholinergic* or anti-cholinergic* or glycopyrronium or scopolamine).ti,ab,kf. (17337)
(antiemetic* or antipsychotic* or haldol or risperidone).ti,ab,kf.
(39037)
(diuretic* or furosemide).ti,ab,kf. (42112)
or/24–36 (2651529)
23 and 37 (2109)
38 and cost (477)