Potential Cost-Effectiveness of Universal Access to Palliative Care for Women with Advanced Breast Cancer in Uganda

Thesis (Master's)--University of Washington, 2017-08Background: While Uganda has a relatively advanced palliative care system developed for people living with HIV, palliative care services are unavailable to most Ugandans who need them. Incidence of advanced breast cancer is increasing and advanced breast cancer patients may benefit from access to home-based palliative care. Objective: We evaluated the potential cost-effectiveness of a universal, home-based, palliative care program for women with advanced breast cancer, compared to the standard of care, which involves limited access to palliative care. Methods: We used a decision-analytic model that utilized estimates from the literature to estimate the incremental cost, incremental effectiveness, and incremental cost-effectiveness ratio (ICER) of providing universal access to palliative care. One-way and probabilistic sensitivity analyses were performed to explore the effects of parameter uncertainty. Results: With an incremental cost effectiveness ratio (ICER) of $I 211,850 (UGX 242,753,988) per disability adjusted life year (DALY) averted, the universal palliative care program was not cost effective by the frequently cited threshold of three times gross domestic product per capita ($I 5,546). The program is relatively low cost (incremental lifetime cost per patient: $I 1,378, UGX 1,578,480). The high ICER is driven largely by a very small marginal difference in disability weight for end-of-life patients with and without palliative care. The model was also sensitive to ongoing staff and transport costs, and costs and use of Amitriptyline (antidepressant) and Biscodyl (laxative). Discussion: Our analysis is highly sensitive to the incremental disability weight from palliative care, estimates of which vary in the literature and are not specific to our population or intervention of interest. Further research is needed on interventions to improve care at the end of life and measures of their benefits