在宅緩和ケアにおける資金提供モデルの比較：包括払制度対出来高払い制度：単一施設前向きコホート研究

With an ageing population, there is an increasing demand for home-based palliative care to improve end-of-life care. Funding models can impact service utilisation and patient outcomes.

To compare two funding models to assess the effects on service utilisation, hospital admission, home death rates and concordance between preferred and actual place of death.

A single-centre, prospective cohort study compared the first 12 months of two funding models. Eligible patients accessing a private health insurance-funded palliative care programme were included. Each funding model had different eligibility criteria: the capitation model (May 2020-April 2021) required a ≤3-month prognosis and preference for home death, while the fee-for-service model (December 2022-November 2023) had a ≤6-month prognosis with no preference.

The capitation cohort had fewer hospital admissions (27% vs. 64%) in the last 4 weeks of life, and a higher rate in home or a residential aged care facility (78% vs. 31%). Concordance with preferred place of death was similar across cohorts (91% vs. 76%). Except for assistants in nursing, the fee-for-service cohort accessed more services, with utilisation increasing near death. In the final 4 weeks, the capitation cohort had higher service use (median 14 vs. 7) and more involvement of assistants in nursing (40% vs. 5%) and medical practitioners (60% vs. 35%).

This is one of the first studies to look into funding models and how funding mechanisms influence service utilisation, intensity and timing. While trends emerged, cohort differences led to variability and limited interpretation.