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

Background: 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. Aim: To synthesise and critically appraise context-specific economic evaluations with comprehensive methodological and quality lenses including decision-making aspects. Design: 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. Data sources: The databases EMBASE, HTA-Database, MEDLINE, and NHS-EE-Database were searched between 2010 and 2024. Results: 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. Conclusions: 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.