| 110
Pensar Enfermagem / v.27 n.01 / October 2023
DOI: 10.56732/pensarenf.v27i1.278
Review Article
How to cite this article: Vidotto PC, Aroni P, Malaquias TSM, Barreto MFC, Haddad MCFL. Cost of
oncological palliative care in home care service: integrative review. Pensar Enf [Internet]. 2023 Oct; 27(1):110-
118. Available from: https://doi.org/10.56732/pensarenf.v27i1.278
Cost of oncological palliative care in home care
service: integrative review
Abstract
Objective
Investigate scientific articles related to the cost of the Home Care Service for
patients undergoing oncology palliative care.
Methods
Integrative literature review, which included primary articles indexed in the PubMed,
Scopus, Virtual Health Library (VHL), Embase, Science Direct and Scielo databases, using
the descriptors: neoplasms; oncology; home care; palliative care; cost analysis; costs.
Results
Ten studies were included, three from the United Kingdom, three from Spain, followed
by two from Italy, one from the United States of America and one from Canada. Studies
have shown lower costs for home hospitalization with monitoring by healthcare teams,
including when analyzing terminally ill cancer patients and disease prognosis.
Conclusion
It was evidenced that the costs of care provided to patients undergoing oncological
palliative care are lower in a home environment than at a hospital level.
Keywords
Medical Oncology; Home Care Services; Palliative Care; Costs and Cost Analysis.
Patrícia Christovão Vidotto
1
orcid.org/0000-0003-1516-7236
Patricia Aroni
2
orcid.org/0000-0001-5092-2714
Tatiana da Silva Melo Malaquias
3
orcid.org/0000-0001-5541-441X
Maynara Fernanda Carvalho Barreto
4
orcid.org/0000-0002-3562-847
Maria do Carmo Fernandez Lourenço Haddad
5
orcid.org/0000-0001-7564-856
1
Nurse. Master in Nursing. Graduate Program in
Nursing, State University of Londrina, Londrina,
Brazil.
2
Nurse. PhD in Nursing. Department of Nursing,
State University of Londrina, Londrina, Brazil.
3
Nurse. PhD in Nursing. Department of Nursing,
State University of the Midwest, Guarapuava, Brazil.
4
Nurse. PhD in Nursing. Nursing Department, State
University of Northern Paraná, Bandeirantes, Brazil.
5
Nurse. PhD in Nursing. Department of Nursing,
State University of Londrina, Londrina, Brazil.
Corresponding author:
Tatiana da Silva Melo Malaquias
E-mail: tatieangel@yahoo.com.br
Received: 15.05.2023
Accepted: 12.09.2023
Pensar Enfermagem / v.27 n.01 / October 2023 | 111
DOI: 10.56732/pensarenf.v27i1.278
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Introduction
Cancer is among the main Chronic No Communicable
Diseases (NCDs) and represents the second leading cause
of death in the world, with one in every six deaths being
related to the disease. Among the most common types of
lung cancer (2.09 million cases), breast (2.90 million cases),
colorectal (1.8 million cases), prostate (1.28 million cases),
non-melanoma skin cancer (1.04 million cases) and
stomach cancer (1.03 million cases).
1
Regarding the severity of NCDs, an analysis by the World
Economic Bank estimated that countries such as Brazil,
China, India, and Russia lose, annually, more than 20
million productive years of life due to NCDs.
2
From this
perspective, Oncological diseases represent a major public
health problem, due to the significant cost of treatment,
hospitalization, and the need for continuity of care for
individuals in palliative care.
According to the World Health Organization (WHO), in a
concept defined in 1990 and updated in 2002 and 2017,
3
palliative care refers to actions that improve the quality of
life of patients and families facing problems associated with
life-threatening illnesses. It aims to prevent and alleviate
suffering, through early identification, correct assessment,
and treatment of pain and other physical, psychosocial, or
spiritual problems.
It is noteworthy that contingency plans focused on de-
hospitalization, and optimization of financial resources are
extremely relevant, as they constitute strategies that aim to
analyze resources and health actions that favor adequate
planning, as well as targeting to the various levels of health
care.
4
Assistance or home care (HC) corresponds to the set of
health actions, integrated into the Health Care Network
(HCN), to guarantee the continuation of care for the
individual who needs care. This service is available in Brazil
through the Unified Health System (SUS), through
multidisciplinary teams and is also offered by other private
service providers, known as home care services.
5
Within this scenario and perspective, in Brazil, Resolution
No. 41/2018 defined together with the Tripartite
Intermanagers Commission of the National Council of
Health Secretaries (CONASS) and municipal secretariats,
provided for guidelines for the organization of palliative
care, in light of continued care integrated, within the scope
of the Unified Health System (SUS). According to Article
5, palliative care must be offered anywhere in the health
care network, at no cost to the patient and their family,
notably in primary care, home care, outpatient care,
urgent/emergency care, and hospital care.
6
Across the world, healthcare costs are expensive. When it
comes to hospital care, it is even higher. Depending on the
evolution of the disease, patients undergoing oncology
palliative care undergo several readmissions. When it is
possible to decrease readmission rates and shift care to
home care, it can lead to a significant difference in hospital
expenses.
7
The cost is the sum of expenses with personnel, material,
physical structure, and equipment used and must be
understood as an important management tool for analyzing
performance, productivity and quality of services.
8
The first stage of the process consists of verifying the costs
of health services, procedures, and treatments. According
to the analysis carried out, pharmacoeconomic evaluations
have different denominations, including: cost-
minimization, cost-effectiveness, cost-utility and cost-
benefit.9 In this sense, economic evaluation in health plays
a prominent role, requiring managers to face new
challenges in the continuous search for efficiency and
effectiveness of activities. Quality associated with the
rational use of resources must be the new challenge for
health service managers.
10-11
Therefore, it is essential to measure health costs, for a
careful analysis of the service scenario to support decision-
making by managers in the selection of tools and
management models that qualify the care provided to the
population involved, especially people with cancer in
palliative care. In view of the above, the objective of this
study was to investigate scientific articles related to the cost
of the Home Care Service for patients undergoing
oncology palliative care.
Methods
This is an Integrative Literature Review that followed six
standardized steps:
12
in step I, the definition of the research
problem and the guiding question were established, using
the acronym PICo,
13
where the “P” refers to the population
study or the patient, or the problem addressed
(Population/Patient/Problem), which in this review refers
to cancer patients; the “I” is the phenomenon of Interest
(Interest), which were the costs of the home care service
for palliative care and the “Co” to the context (Context),
what was home care. Therefore, the guiding question of
the research was: “What is the cost of home care for
patients undergoing oncology palliative care?”
In stage II, the inclusion criteria were defined, which were
indexed articles, complete texts without definition of
temporality or country of publication, in Portuguese,
Spanish and English, related to the guiding question and
developed in human beings, without restriction on age
range in palliative oncology care.
Studies that addressed palliative care in the hospital area,
letters to the editor, duplicates, opinion and review articles
of any nature, theoretical reflection, comments, essays,
preliminary notes, editorials, letters, theses and
dissertations, course completion works, manuals,
summaries in annals or periodicals, dossiers, official
documents, health policies, hospital management reports,
books and book chapters were excluded.
Data collection took place in October 2021 in databases
and electronic libraries: Scopus; BASIS; Science Direct,
PubMed (MedLine), Scielo, Web of Science and the Virtual
Health Library (VHL), with the descriptors presented by
the search strategy in Table 1.
112 | Malaquias, T.
Article (To be added by the editorial staff)
Table 1 – Search string to identify studies on the costs of palliative oncology care in Home Care Services
The studies were analyzed descriptively using tables. The
classification regarding the level of evidence was carried out
according to Melnyk and Fineout-Overhol,
14
which
establishes levels from 01 to 07: level 1, the evidence comes
from a systematic review or meta-analysis of all relevant
randomized controlled clinical trials or clinical guidelines
based on systematic reviews of randomized controlled
clinical trials; level 2, evidence derived from at least one
well-designed randomized controlled clinical trial; level 3,
evidence obtained from well-designed clinical trials without
randomization; level 4, evidence from well-designed cohort
and case-control studies; level 5, evidence from a systematic
review of descriptive and qualitative studies; level 6,
evidence derived from a single descriptive or qualitative
study; level 7, evidence from the opinion of authorities
and/or the report of expert committees.
As it is an integrative review, the research was not
submitted to the Research Ethics Committee.
Results
Identified 84 articles according to the initial search strategy.
Of these, five were duplicates, resulting in a total of 79.
There were 18 articles that addressed the research question;
and after reading the full texts, ten studies were selected to
be part of this review. The search, selection and analysis
process of studies was carried out by two independent
reviewers, with the help of the Rayyan reference manager
software and any disagreements were resolved by a third
reviewer.
Figure 01 represented by Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA)
15
presents the study selection flow.
Descriptors
Search strategy
Initial number of
articles
MeSH
“Cost analysis AND home care AND
palliative cancer patients”
2
MeSH
“Cost analysis AND home care AND
palliative cancer patients”
11
DeCS
(Home visit OR Home care) AND
(Palliative treatment OR Palliative care
OR Palliative care) AND (Oncology
OR Cancer OR Neoplasia) AND
(Cost analysis OR Costs)
9
MeSH
'Cost analysis' AND ' home care'
AND palliative AND care
29
MeSH
(Cost analysis) AND (home care)
AND (palliative care)
3
MeSH
Cost analysis' AND 'home care' AND
palliative AND care
30
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Figure 1 – Flowchart of the process of identification, selection, eligibility, and inclusion of studies. Source: Adapted from
PRISMA 2020
For the analysis and synthesis of the ten selected articles, a
synoptic table was used containing title, year and country
and another with objective(s), method, results and
recommendations/conclusions (table 2).
16
The articles were categorized by theme: comparison of the
cost of home care versus hospital service; cost in the last
days-months of life; and cost according to the prognosis of
the disease. The number of articles published
internationally stands out: three from the United
Kingdom,
17-19
three from Spain,
20-22
one from the United
States of America,
23
two from Italy,
24-25
one from
Canada,26 starting publications in 1986.
Table 3 presents data relating to the cost analysis of cancer
patients in home care services.
Table 2 – Characterization of the ten primary articles included in the integrative review according to title, year, and country.
Title
Ano
País
A comparative assessment of home versus hospital comprehensive treatment for advanced cancer
patients.
1986
USA*
A comparative cost analysis of terminal cancer care in home hospice patients and controls
1987
United Kingdom
A cost-minimization study of cancer patients requiring a narcotic infusion in hospital and at
home
1991
United Kingdom
Home palliative care as a cost-saving alternative: Evidence from Catalonia
2001
Spain
Cost analysis of a domiciliary program of supportive and palliative care for patients with
hematologic malignancies.
• 2007
Italy
Use of resources and costs of palliative care with parenteral fluids and analgesics in the home
setting for patients with end-stage cancer
2010
United Kingdom
Studies identified in the database
(84)
Exclusion of duplicate studies (5)
Studies selected for reading titles and
abstracts (79)
Studies excluded after reading (61)
Studies eligible for full-text reading
(18)
Studies excluded after reading (08)
1. Hospital-based approach
to palliative care (05)
2. Full text not found (03)
Studies included in the review (10)
Identification
Selection
Eligibility
Inclusion
114 | Malaquias, T.
Article (To be added by the editorial staff)
Resource utilization and cost analyses of home-based palliative care service provision: The
Niagara West End-of-Life Shared-Care Project
2012
Canada
Actividad asistencial y costes en los últimos 3 meses de vida de pacientes fallecidos con cáncer en
Euskadi
2017
Spain
Comparación directa de los costes sanitarios en los 2 últimos meses de vida en pacientes
oncológicos a partir de certificados de defunción en un área periurbana según reciban o no
atención en su domicilio por un equipo de cuidados paliativos
2018
Spain
Early Palliative Home Care versus Hospital Care for Patients with Hematologic Malignancies: A
Cost-Effectiveness Study
2020
Italy
Note: USA* – United States of America
Table 3 – Selected publications referring to the cost analysis of cancer patients in home care services compared to hospital
services.
Base
Title /
Level of Evidence
Periodical/
Year/Country/DOI
Objective
Main results
Scopus
A comparative
assessment of home
versus hospital
comprehensive
treatment for
advanced cancer
patients.
Evidence - IV
J Clin Oncol. 1986.
United States
DOI:
https://doi.org/10.1200/
JCO.1986.4.10.1521
Prospectively compare the costs
of home and hospital treatment
for patients with advanced
cancer
Home treatment had a daily cost
of US$256 lower than the
hospital cost
Science
Direct
A comparative cost
analysis of terminal
cancer care in home
hospice patients and
controls.
Evidence - IV
Journal of Chronic
Diseases. 1987. United
Kingdom
DOI:
https://doi.org/10.1016
/0021-9681(87)90132-9
To compare the costs of the last
90 days of life in 98 terminal
cancer patients treated by a
home care service versus
hospital care
The costs of 24-hour medical
and nursing care at home and
support for their families had an
average cost of US$6,477 versus
US$6,502 for the hospital daily
rate
Scopus
A cost-minimization
study of cancer
patients requiring a
narcotic infusion in
hospital and at
home.
Evidence - III
Journal of Clinical
Epidemiology. 1991.
United Kingdom
DOI:
https://doi.org/10.1016/
0895-4356(91)90043-9
Compare the cost in Canadian
dollars of cancer management in
patients who required narcotic
infusions in the hospital and at
home
Medical costs averaged
C$369.72/day of hospital stay
and C$150.24/day of home care
(saving C$219.48/day in 1988).
Narcotic costs were the same for
any patient in both settings
PubMed
Use of resources and
costs of palliative
care with parenteral
fluids and analgesics
in the home setting
for patients with end-
stage cancer.
Evidence - IV
Ann Oncol. 2010. United
Kingdom
DOI:
https://doi.org/10.1023/
A:1008364401890
Identify the cost of home care
and the cost of hospitalized
patients
The daily cost for each patient
was between US$250 and
US$300, half of which is for
hospital expenses. A hypothetical
control group (n=25) was
constructed based on current
practice and chart review cost
approximately $750/day. With an
average treatment period of 16
days, this means savings of
US$8,000 per patient
Scopus
Resource utilization
and cost analyses of
home-based palliative
care service
provision: the
Niagara West End-
of-Life Shared-Care
Project.
Evidence - IV
Palliative Medicine. 2012.
Canada
DOI:10.1177/026921631
1433475
Analyze the cost of cancer
patients receiving home care
Costs for all patient-related
services (in 2007) were
C$1,625,658.07 or
C$17,112.19/patient, being
C$117.95/day. It was observed
that home care is less expensive
than hospital care
Scopus
Early Palliative
Home Care versus
Hospital Care for
Patients with
Hematologic
Malignancies: A
Cost-Effectiveness
Study.
Journal of palliative
medicine 2020.
Italy
DOI:
https://doi.org/10.1089/
jpm.2020.0396
Compare costs and outcomes
between early palliative home
care and hospital care for early
or terminally ill hematological
palliative patients
Home care generated weekly
savings of €2,314.9 for the
healthcare provider, at a cost of
€85.9 for the family, and was
cost-effective for preventing
infections
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Evidence - III
Table 4 presents publications according to categorization,
referring to palliative patients at the end of life, compared
to the costs of palliative patients in the hospital.
Table 4 – Selected publications referring to cost analysis in the last days-months of life of patients with oncological diseases in
home care services.
Base
Title /
Level of Evidence
Periodical/Year/Cou
ntry/
DOI
Objective
Main results
Scopus
Home palliative care as a
cost-saving alternative:
Evidence from
Catalonia.
Evidence - IV
Palliative Medicine.
2001. Spain
DOI:
https://doi.org/10.119
1/02692160167832025
0
Compare the care
resources consumed
during the last month
of life of patients
undergoing palliative
treatment who died of
cancer
The costs of hospital care were 71%
higher than home care
Scielo
Actividad asistencial y
costes en los últimos 3
meses de vida de
pacientes fallecidos con
cáncer en Euskadi.
Evidence - IV
Gaceta Sanitaria. 201.
Spain
DOI:
https://dx.doi.org/10.1
016/j.gaceta.2016.06.00
5
Analyze the use of
health resources and
budget in the last
months of life of the
population who died
of malignant neoplasia
in the Basque
Autonomous Country
(Spain)
People who died in hospital had an
average cost of €14,794 approximately
double that of people who died at
home, and €7,491
Science
Direct
Comparación directa de
los costes sanitarios en
los 2 últimos meses de
vida en pacientes
oncológicos a partir de
certificados de defunción
en un área periurbana
según reciban o no
atención en su domicilio
por un equipo de
cuidados paliativos
Evidence - IV
Medicina Paliativa.
2018. Spain
DOI:
10.1016/j.medipa.2017.
05.003
To compare the
healthcare costs of
care in the last two
months of life for
patients with advanced
cancer, based on death
certificates, in a
metropolitan area of
Madrid, depending on
whether or not they
were monitored at
home by a home
palliative care team
The average cost per patient was
€3,158, regardless of whether or not
they were monitored by a palliative care
team.
Table 5 describes the study that addressed the cost
according to the prognosis of the disease.
Table 5 – Selected publication referring to cost analysis according to the prognosis of oncological disease in home care services.
Base
Title /
Level of
Evidence
Periodical/Year/Count
ry/DOI
Objective
Main results
Scopus
Cost analysis of a
domiciliary
program of
supportive and
palliative care for
patients with
hematologic
malignancies.
Evidence - IV
Haematologica. 2007.
Italy
• DOI:
https://doi.org/10.3324
/haematol.10324
•
•
To analyze the use of
resources and costs
of a home palliative
care program for
four different groups,
subdivided according
to the status of
hematological
malignancy
The cost of the home care program was less
than charges but exceeded district rates for
cancer patients. In hematology patients, costs
differ according to disease status and
transfusion requirements.
Discussion
The results of the studies demonstrate that the de-
hospitalization of patients in palliative care must be
predicted through descriptive and qualitative economic
aspects. It needs to be based on the exchange and
discussion of cases in multidisciplinary teams, with the
participation of the patient and family, in the period prior
to hospital discharge, seeking to address possible needs,
thus characterizing a continuous, organized, and structured
process. Thus, the use of these procedures would make it
possible to meet all the necessary elements to implement
the procedure and resolve the expectations of the patient
and their family regarding home care.
27
Some studies also reinforce that cost-effectiveness and
utility costs are greater when comparing home and hospital
116 | Malaquias, T.
Article (To be added by the editorial staff)
care, both for the patient and the family, emphasizing that
the quality of life of patients and family support are
greater.
25
There is evidence that the costs of home palliative care are
lower than the costs of hospital care, as it has been
observed that care provided by teams at home contributes
to reducing hospital readmission rates and the average
length of stay of patients in hospital, in addition to reducing
the number of interventions and complications resulting
from hospitalization, such as nosocomial infections.
28
A study carried out in Italy demonstrated that the costs of
home palliative care for patients with hematological
malignancies are also lower than the costs of standard
hospital care.
26
It is important to highlight that, for this type of care, the
consent of the patient and/or family member is extremely
important and, despite the possibility of death occurring at
home, it is necessary that, during the period of care, the
patient and family are capable of developing the ability to
deal with such a situation.
The care plan, prepared by the team, must guide the family
and caregivers on how to care for the patient, as one of the
great advantages observed in home care is the fact that it
allows the individual to have their needs met according to
their preferences, without having to follow the strict rules
and schedules of a hospital, in addition to being able to
enjoy family life.
2
In cities in Spain, the average cost per patient in a Home
Care Program and Support Equipment (Programa d'Atenció
Domiciliària i Equips de Suport - PADES) is substantially
lower than in the non-PADES group, with an increase of
71%.19 Just like monitoring, the cost of patients who died
in hospital was €14,794, almost double that of those who
died at home, according to the cost assessment carried out
(€7,491).
21
In a study carried out in Brazil, relating the profile of
patients assisted with the costs of home care and in the case
of hospital stays, the results suggest that the average
patient/day cost of home care was R$ 28.26-DP4.10 (US$
12.03 – DP1.74), while the cost of the patient/day of
hospitalization was R$294.46 - DP308.69 (US$ 125.30 –
DP131.36), or we reaffirm that the patient is in home care.
Generally speaking, it tends to be less.
29
The modality of home care related to palliative care is part
of the health policy discussion agenda for Latin American
countries that, being justified by the high costs of hospital
inpatient care, seeks a way to optimize two financial
resources. On the one hand, home care can reduce hospital
expenses, on the other hand, it can increase family health
care costs. Research shows that Latino families that
exclusively use public systems for medical care are those
with the greatest economic vulnerability.
30
The verified data in our studies favor non-home
oncological palliative care, because also two costs will be
minors, or the patient finds himself in a family
environment, with his loved ones, where he will be able to
feel more comfortable and safer when receiving care.
Likewise, it is important that future health professionals be
trained based on their training to perform home care of
patients in oncological palliative care, with a vision for the
health process as well, and understand it in its
biopsychosocial context.
It is suggested that new research may be developed,
through more open studies, that compare the costs of
home and hospital care for patients in oncological palliative
care, to subsidize the formulation of effective public
policies that reinforce home care and de-hospitalization.
Conclusion
The results of the two studies presented in this review
suggest that the costs of care for cancer patients in the
home environment are less than when we are hospitalized,
regardless of the treatment phase.
Home assistance can also be efficient in the quality of
accompaniment to the patient in his last days of life, since
it is possible for the family (caregiver) to offer emotional
support and adequate infrastructure, as well as having
adequate accompaniment from a multidisciplinary team,
favored by Public Policies that reinforce home care and de-
hospitalization of patients in oncological palliative care.
Limitations of the study
As a limitation for the development of this review we can
highlight the lack of publications addressed to the costs
related to oncological palliative care in home care,
impacting the generalization of two results for other
regions that perform this type of care.
Authors’ contributions
PCV: Conception and design of the study; Data collection;
Data analysis and interpretation; Writing the manuscript;
Critical revision of the manuscript.
PA: Conception and design of the study; Analysis and
interpretation of the data; Writing of the manuscript;
Critical revision of the manuscript.
MFCB: Conception and design of the study; Analysis and
interpretation of the data; Writing of the manuscript;
Critical revision of the manuscript.
TSMM: Conception and design of the study; Analysis and
interpretation of the data; Writing of the manuscript;
Critical revision of the manuscript.
MCFLH: Conception and design of the study; Data
collection; Data analysis and interpretation; Writing the
manuscript; Critical revision of the manuscript.
Conflicts of interest
The authors declare that there is no conflict of interest.
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