No Time to Waste: An Appraisal of Value at the End of Life

Kieran L Quinn; Murray Krahn; Thérèse A Stukel; Yona Grossman; Russell Goldman; Peter Cram; Allan S Detsky; Chaim M Bell

doi:10.1016/j.jval.2022.05.004

No Time to Waste: An Appraisal of Value at the End of Life

Value Health. 2022 Jun 8:S1098-3015(22)01966-0. doi: 10.1016/j.jval.2022.05.004. Online ahead of print.

Authors

Kieran L Quinn¹, Murray Krahn², Thérèse A Stukel³, Yona Grossman⁴, Russell Goldman⁵, Peter Cram⁶, Allan S Detsky⁷, Chaim M Bell⁶

Affiliations

¹ Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada. Electronic address: kieran.quinn@sinaihealth.ca.
² Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada; Toronto Health Economics and Technology Assessment Collaborative, Toronto, ON, Canada.
³ Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada.
⁴ Arts and Science Program, McMaster University, Hamilton, ON, Canada.
⁵ Interdepartmental Division of Palliative Care, Sinai Health System, Toronto, ON, Canada; Temmy Latner Centre for Palliative Care, Toronto, ON, Canada.
⁶ Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto and Ottawa, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada.
⁷ Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada.

PMID: 35690518
DOI: 10.1016/j.jval.2022.05.004

Abstract

Objectives: The use of economic evaluations of end-of-life interventions may be limited by an incomplete appreciation of how patients and society perceive value at end of life. The objective of this study was to evaluate how patients, caregivers, and society value gains in quantity of life and quality of life (QOL) at the end of life. The validity of the assumptions underlying the use of the quality-adjusted life-years (QALY) as a measure of preferences at end of life was also examined.

Methods: MEDLINE, Embase, CINAHL, PsycINFO, and PubMed were searched from inception to February 22, 2021. Original research studies reporting empirical data on healthcare priority setting at end of life were included. There was no restriction on the use of either quantitative or qualitative methods. Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all included studies. The primary outcomes were the value of gains in quantity of life and the value of gains in QOL at end of life.

Results: A total of 51 studies involving 53 981 participants reported that gains in QOL were generally preferred over quantity of life at the end of life across stakeholder groups. Several violations of the underlying assumptions of the QALY to measure preferences at the end of life were observed.

Conclusions: Most patients, caregivers, and members of the general public prioritize gains in QOL over marginal gains in life prolongation at the end of life. These findings suggest that policy evaluations of end-of-life interventions should favor those that improve QOL. QALYs may be an inadequate measure of preferences for end-of-life care thereby limiting their use in formal economic evaluations of end-of-life interventions.

Keywords: delivery of healthcare; end of life; high-value care.

Publication types

Review