Abstract
Background
Guidelines for economic evaluations often request that costs and outcomes beyond the patient are captured; this can include carers and also other affected parties. End-of-life care is one context where impacts of care spill over onto those other than patients, but there is little evidence about who should be included within economic evaluations.
Objective
The purpose of this article was to examine (1) how many people are close to those at the end of life (2); their characteristics; and (3) what influences the network size at the end of life.
Methods
In-depth interviews were conducted with 23 participants who were either recently bereaved or had somebody close to them currently receiving end-of-life care. Interviews were used in conjunction with hierarchical mapping to explore the network size and composition and influences upon these networks. Interviews were transcribed verbatim. Descriptive statistics were used to analyse the hierarchical maps and this information was combined with a constant comparative analysis of the qualitative data.
Results
On average, close-person networks at the end of life contained eight individuals, three of whom were rated as being ‘closest’. These were typically family members, although in a small number of cases non-family members were included amongst the closest individuals. There was variation in terms of network composition. Qualitative analyses revealed two key influences on network size: death trajectory (those with cognitive problems/diseases towards the end of life had smaller networks) and family size (larger families had larger networks).
Conclusions
The findings of this article have important implications for researchers wishing to include those affected by end-of-life care in an economic evaluation. Focussing on the three closest individuals would be a key starting point for economists seeking to capture spill-overs, whilst a truly societal perspective would require looking beyond proximal family members. This article further discusses the implications of including close persons in economic evaluations for decision makers.
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References
Drummond M, Sculpher M, Torrance G, O’Brien B, Stoddart G. Methods for the economic evaluation of health care programmes. 3rd ed. Oxford: Oxford University Press; 2005.
NICE. NICE guide to the methods of technology appraisal. Pharmacoeconomics. 2008;26:725–7. https://doi.org/10.2165/00019053-200826090-00002.
NICE. Guide to the methods of technology appraisal. London: NICE; 2013.
NICE. Guide to the methods of technology appraisal. London: NICE; 2004.
National Healthcare Institute. Guideline for economic evaluations in healthcare. Zorginstituut Nederland 2016.
Sanders GD, Neumann PJ, Basu A, Brock DW, Feeny D, Krahn M, et al. Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine. JAMA. 2016;316:1093–103. https://doi.org/10.1001/jama.2016.12195.
Brouwer W, van Exel N, van Gorp B, Redekop W. The CarerQol instrument: a new instrument to measure care-related quality of life of informal caregivers for use in economic evaluations. Qual Life Res. 2006;15:1005–21. https://doi.org/10.1007/s11136-005-5994-6.
Brouwer WBF. Too important to ignore. Pharmacoeconomics. 2006;24:39–41. https://doi.org/10.2165/00019053-200624010-00003.
Canaway A, Al-Janabi H, Kinghorn P, Bailey C, Coast J. Development of a measure (ICECAP-close person measure) through qualitative methods to capture the benefits of end-of-life care to those close to the dying for use in economic evaluation. Palliat Med. 2017;31(1):53–62. https://doi.org/10.1177/0269216316650616.
Coast J. Strategies for the economic evaluation of end-of-life care: making a case for the capability approach. Expert Rev Pharmacoecon Outcomes Res. 2014;14:473–82. https://doi.org/10.1586/14737167.2014.914436.
Coast J, Bailey C, Canaway AG. Measuring and valuing outcomes for care at the end of life: the capability approach. In: Round J, editor. Care at the end of life. Cham: Springer International Publishing; 2016. pp. 89–101.
Hoefman R, van Exel J, Brouwer W. Measuring the impact of caregiving on informal carers: a construct validation study of the CarerQol instrument. Health Qual Life Outcomes. 2013;11:173. https://doi.org/10.1186/1477-7525-11-173.
Al-Janabi H, van Exel J, Brouwer W, Coast J. A framework for including family health spillovers in economic evaluation. Med Decis Making. 2016;36:176–86. https://doi.org/10.1177/0272989X15605094.
Al-Janabi H, Flynn TN, Coast J. Estimation of a preference-based carer experience scale. Med Decis Making. 2011;31:458–68. https://doi.org/10.1177/0272989X10381280.
Coast J. Strategies for the economic evaluation of end-of-life care: making a case for the capability approach. Expert Rev Pharmacoecon Outcomes Res. 2014;14:473–82. https://doi.org/10.1586/14737167.2014.914436.
Haycox A. Optimizing decision making and resource allocation in palliative care. J Pain Symptom Manage. 2009;38:45–53.
Cameron J, Parkes CM. Terminal care: evaluation of effects on surviving family of care before and after bereavement. Postgrad Med J. 1983;59:73–8.
Ransford HE, Smith ML. Grief resolution among the bereaved in hospice and hospital wards. Soc Sci Med. 1991;32:295–304.
Schulz R, Mendelsohn AB, Haley WE, Mahoney D, Allen RS, Zhang S, et al. End-of-life care and the effects of bereavement on family caregivers of persons with dementia. N Engl J Med. 2003;349:1936–42.
Christakis NA, Iwashyna TJ. The health impact of health care on families: a matched cohort study of hospice use by decedents and mortality outcomes in surviving, widowed spouses. Soc Sci Med. 2003;57:465–75.
Stroebe M, Schut H, Stroebe W. Health outcomes of bereavement. Lancet. 2007;370:1960–73.
Granovetter M. The strength of weak ties. Am J Sociol. 1973;78:1360–80. https://doi.org/10.2307/2776392.
Marsden PV, Campbell KE. Reflections on conceptualizing and measuring tie strength. Soc Forces. 2012;91:17–23. https://doi.org/10.1093/sf/sos112.
Petróczi A, Nepusz T, Bazsó F. Measuring tie-strength in virtual social networks. Connection. 2007;27(2):39–52.
Starzyk KB, Holden RR, Fabrigar LR, Macdonald TK. The personal acquaintance measure: a tool for appraising one’s acquaintance with any person. J Pers Soc Psychol. 2006;90:833–47. https://doi.org/10.1037/0022-3514.90.5.833.
Aron A, Mashek D, Aron E, editors. Handbook of closeness and intimacy. London: Psychology Press; 2004. pp. 27–30.
Antonucci TC. Hierarchical mapping technique. Gen J Am Soc. 1986;10:10–2.
Moreno J. Who shall survive? A new approach to the problem of human interrelations. Beacon House, Beacon, New York; 1934.
Cornwell B, Schumm LP, Laumann EO, Graber J. Social networks in the NSHAP study: rationale, measurement, and preliminary findings. J Gerontol Ser B. 2009;64B:i47–55. https://doi.org/10.1093/geronb/gbp042.
Antonucci TC, Akiyama H. Social networks in adult life and a preliminary examination of the convoy model. J Gerontol. 1987;42:519–27. https://doi.org/10.1093/geronj/42.5.519.
Tomini F, Tomini SM, Groot W. Understanding the value of social networks in life satisfaction of elderly people: a comparative study of 16 European countries using SHARE data. BMC Geriatr. 2016;16:203. https://doi.org/10.1186/s12877-016-0362-7.
NHS Choices. Hospice care: end of life care guide. NHS choices 2018. Available from: https://www.nhs.uk/Planners/end-of-life-care/Pages/hospice-care.aspx. Accessed 16 Jan 2018.
Frank O, Snijders T. Estimating the size of hidden populations using snowball sampling. J Off Stat. 1994;10:53–67. https://doi.org/10.1214/aoms/1177705148.
Ingleton C, Morgan J, Hughes P, Noble B, Evans A, Clark D. Carer satisfaction with end-of-life care in Powys, Wales: a cross-sectional survey. Health Soc Care Community. 2004;12:43–52. https://doi.org/10.1111/j.1365-2524.2004.00467.x.
Rempel GR, Neufeld A, Kushner KE. Interactive use of genograms and ecomaps in family caregiving research. J Fam Nurs. 2007;13:403–19. https://doi.org/10.1177/1074840707307917.
McCormick KM, Stricklin S, Nowak TM, Rous B. Using eco-mapping to understand family strengths and resources. Young Except Child. 2008;11:17–28. https://doi.org/10.1177/1096250607311932.
King N, Bravington A, Brooks J, Hardy B, Melvin J, Wilde D. The Pictor technique: a method for exploring the experience of collaborative working. Qual Health Res. 2013;23:1138–52. https://doi.org/10.1177/1049732313495326.
Antonucci TC, Akiyama H, Takahashi K. Attachment and close relationships across the life span. Attach Hum Dev. 2004;6:353–70. https://doi.org/10.1080/1461673042000303136.
Antonucci TC, Akiyama H, Lansford J. Negative effects of close social relations. Fam Relat. 1998;47:379–84.
Hlebec V, Mrzel M, Kogovšek T. Social support network and received support at stressful events. Metodološki Zv. 2009;6:155–71.
Santos JD, Levitt MJ. Intergenerational relations with in-laws in the context of the social convoy: theoretical and practical implications. J Soc Issues. 2007;63:827–43. https://doi.org/10.1111/j.1540-4560.2007.00539.x.
Canaway A, Al-Janabi H, Kinghorn P, Bailey C, Coast J. Incorporating novel qualitative methods within health economics: the use of pictorial tools. In: Coast J, editor. Qualitative Methods for Health Economics. London: Rowman & Littlefield; 2017. pp. 205–16.
Glaser BG. The constant comparative method of qualitative analysis. Soc Probl. 1965;12:436–45. https://doi.org/10.1525/sp.1965.12.4.03a00070.
Ritchie J, Lewis J. Qualitative research practice: a guide for social science students and researchers, 2nd edn, vol. 1. London: SAGE Publications; 2013.
Mays N, Pope C. Qualitative research in health care: assessing quality in qualitative research. BMJ. 2000;320:50–2. https://doi.org/10.1136/bmj.320.7226.50.
ONS. Deaths registered in England and Wales: 2017. 2018. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsregistrationsummarytables/2017. Accessed 30 Jul 2018.
Ray RA, Street AF. Ecomapping: an innovative research tool for nurses. J Adv Nurs. 2005;50:545–52. https://doi.org/10.1111/j.1365-2648.2005.03434.x.
Stansfeld S, Marmot M. Deriving a survey measure of social support: the reliability and validity of the close persons questionnaire. Soc Sci Med. 1992;35:1027–35. https://doi.org/10.1016/0277-9536(92)90242-I.
Antonucci TC, Israel B. Veridicality of social support: a comparison of principal and network members’ responses. J Consult Clin Psychol. 1986;54:432–7. https://doi.org/10.1037/0022-006X.54.4.432.
Marsden PV. Network data and measurement. Ann Rev. 1990;16:435–63.
Age UK. Loneliness: the state we’re in. 2012. Available from: http://www.ageuk.org.uk/brandpartnerglobal/oxfordshirevpp/documents/loneliness the state we are inreport 2013.pdf. Accessed 3 Mar 2019.
Burstow P. Dying alone: assessing isolation, loneliness and poverty. 2005. Available from: http://image.guardian.co.uk/sys-files/Society/documents/2006/04/07/Dying_Alone_Isolation_Report2final.doc. Accessed 2 Mar 2019.
Hoefman RJ, van Exel J, Brouwer WBF. Measuring care-related quality of life of caregivers for use in economic evaluations: CarerQol tariffs for Australia, Germany, Sweden, UK, and US. Pharmacoeconomics. 2017;35:469–78. https://doi.org/10.1007/s40273-016-0477-x.
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Funding
This work was supported by the European Research Council (Grant No. 261098 EconEndLife).
Conflict of Interest
Alastair Canaway, Hareth Al-Janabi, Philip Kinghorn, Cara Bailey and Joanna Coast have no conflicts of interest that are directly relevant to the content of this article.
Data Availability
The individual-level data generated during and/or analysed during this study are not publicly available owing to a lack of consent for use in this manner. Aggregated data are available from the corresponding author on reasonable request.
Author Contributions
AC was responsible for conducting the research and for the drafting of the manuscript. All authors were involved in the development and design of the study. All authors contributed to the analysis of the data. All authors reviewed, commented and edited drafts of the manuscript.
Appendices
Appendix 1 Example of advert
1.1 Volunteers Required for Study on the End of Life and Bereavement
Have you been bereaved in the last 6–24 months and would feel comfortable discussing your experience with a researcher? Alternatively, is somebody close to you currently receiving end-of-life care? If so, then we would like to invite you to participate in our study investigating how the end of life impacts family and friends.
The study aims to improve the evaluation of end-of-life care in the UK. Confidentiality and sensitivity will be guaranteed. You will be sent additional information and be able to discuss the study with the researcher before being asked to decide whether or not to participate. For more information, email Alastair Canaway at axc105@bham.ac.uk
Appendix 2 Hierarchical mapping template
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Canaway, A., Al-Janabi, H., Kinghorn, P. et al. Close-Person Spill-Overs in End-of-Life Care: Using Hierarchical Mapping to Identify Whose Outcomes to Include in Economic Evaluations. PharmacoEconomics 37, 573–583 (2019). https://doi.org/10.1007/s40273-019-00786-5
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DOI: https://doi.org/10.1007/s40273-019-00786-5