title: Preferences for end-of-life care among community-dwelling older adults and patients with advanced cancer: A discrete choice experiment.
abstract: Singapore is in the midst of several healthcare reforms in efforts to finance and deliver health services for a rapidly aging population. The primary focus of these reforms is to make healthcare services, including those at the end of life (EOL), affordable. Given the increasingly high health care costs at the EOL, policy makers need to consider how best to allocate resources. One strategy is to allocate resources based on the preferences of sub-populations most likely to be affected. This paper thus aims to quantify preferences for EOL care both among community dwelling older adults (CDOAs) and among patients with a life-limiting illness. A discrete choice experiment was administered to CDOAs and advanced cancer patients in Singapore and willingness to pay (WTP) for specific EOL improvements was estimated. We find that patients have a higher WTP for nearly all EOL attributes compared with CDOAs. We also show that, for both groups, moderate life extension is not the most important consideration; WTP for one additional life year is lower than common thresholds for cost-effectiveness. Irrespective of whose preference are considered, the results highlight the importance of pain management and supporting home deaths at the EOL, perhaps at the expense of public funding for costly but only marginally effective treatments.
authors.affiliation: Lien Centre for Palliative Care, Duke-NUS Graduate Medical School, Singapore, Singapore; Program in Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore, Singapore; Duke-Global Health Institute, Duke University, Durham, NC, USA. Electronic address: eric.finkelstein@duke-nus.edu.sg.
authors.forename: Eric A
authors.initials: EA
authors.lastname: Finkelstein
authors.affiliation: Program in Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore, Singapore. Electronic address: marcel.bilger@duke-nus.edu.sg.
authors.forename: Marcel
authors.initials: M
authors.lastname: Bilger
authors.affiliation: Institute for Choice, University of South Australia, Sydney, Australia. Electronic address: terry.flynn@unisa.edu.au.
authors.forename: Terry N
authors.initials: TN
authors.lastname: Flynn
authors.affiliation: Lien Centre for Palliative Care, Duke-NUS Graduate Medical School, Singapore, Singapore; Program in Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore, Singapore. Electronic address: chetna.malhotra@duke-nus.edu.sg.
authors.forename: Chetna
authors.initials: C
authors.lastname: Malhotra
mesh_terms: D002755:Choice Behavior; D005260:Female; D005382:Financing, Personal; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000473:pathology*; D057240:Patient Preference; D012846:Singapore; D011795:Surveys and Questionnaires; D013727:Terminal Care
keywords: Advanced cancer; Discrete choice experiment; End-of-life; Willingness-to-pay