Background
Methods
Part 1
Part 2
Results
Part 1
Classification of innovation | Types of innovation and examples of what is involved | Publications providing quantitative data included in this review | ||
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1 | Facilitating entry into the hospice and community care system | Single point of access | Access to a range of medical, nursing and social care services for patients, carers and healthcare professionals via a single telephone number. | [27] |
2 | Preventing hospital admission | 2a; Care home innovations | A mixed group, including training programmes for nursing home staff. | |
2b; Palliative care support in the community, 24/7 hospice at home service | Coordinated palliative care delivered in the patient’s home through regular visits by specialist medical and nursing staff, often in association with a hospice. | |||
2c; 24/7 helpline | Support for patients, carers, paramedics and non-specialist doctors and nurses. | |||
2d; Telehealth/ telecaring | Provision of healthcare remotely using telecommunication technology. | |||
2e; Ambulance staff education | Training for better communication and decision-making when attending patients at the end of life. | [59] | ||
2f; Integrated palliative care | Coordinated input from different healthcare professionals and caregivers. | |||
2 g; Palliative care outreach in rural areas | Palliative consultant attends the patient in their own home and coordinates care. | |||
3 | Facilitate discharge | 3a; Hospital or emergency department-based discharge service | Patients requesting or considered suitable for discharge into supported care (community, nursing home, hospice) are identified by a hospital-based doctor or nurse who facilitates onward management. | |
3b; Nurse-led palliative care inpatient capacity expansion | Offering additional nurse-led beds for less complex patients. | [78] |
Part 2
Overview
1. Single point of access
2a; care home innovations
Author, date and journal | Study design | Sample and setting | Research focus | Relevant results | Wider implications | Limitations |
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Garden et al.; 2016; Clinical Medicine [28] | Mixed methods. | 7 dementia care homes in Boston, UK, registered for the intervention programme, commencing in March 2011. 250 staff were trained. | To explore the impact of a care home educational programme (Bromhead Care Home Service) on hospital admissions/place of death for palliative residents. | From baseline, admissions were reduced by 66 in the first year and 111 by the third year, which represented a 55% decrease. 102 care plans were completed by April 2013. 4 of 102 patients wanted to die in hospital. Of the 68 residents who died during follow up, 67 died in preferred place. | Care home educational programmes such as the Bromhead Care Home Service could reduce hospital admissions for dementia patients. | Evaluation done in-house. Evaluation was done retrospectively, chance of recall bias. |
Livingston et al.; 2013; International Psychogeriatrics [29] | Mixed-methods retrospective. | 120 Jewish residents with dementia and 90 nursing and care staff at a care home in London, UK. The educational intervention was a 10-session, manualised, interactive staff training programme. | To analyse the impact of a care home educational programme on outcomes, including place of death. | Significant increase in residents dying in the care home vs. hospital (47% vs.76%, p = 0.02). Trend toward a decrease in the number of days spent in hospital during the last 3 months of life after intervention (median 4 vs. 1.25). | Increased care home education is associated with a decrease in hospital deaths and hospital days during the last months of life. | May not replicate in non-Jewish care homes. Non-randomised. |
Rantz et al.; 2015; Journal of Nursing Care Quality [30] | Mixed-methods longitudinal. | 16 American nursing homes where hospital rates were among the country’s highest for hospital 30-day readmission and the Missouri Quality Initiativea intervention was in place. | To examine the Missouri Quality Initiative’s effect on avoidable hospital admissions (other variables measured were polypharmacy and antipsychotic medication use, care discussions and completion of Advance Directive and the introduction of secure communication for electronic transfer of health information to other services). | Transfer rates steadily declined approximately 9 months after programme implementation. Hospital transfers per 1000 days were 1.7 in 2014 and 1.3 in 2015 and was on track for 1.1 in 2016. Education was a theme that care staff believed reduced hospital admissions. They believed the advanced practice registered nurses were key in improving assessment skills through training. All staff members were willing to be involved in the programme, aiding the reduction further. Reports provided a visual picture of nursing staff progress. | The Missouri Quality Initiative reduced unnecessary hospital admissions in a nursing home setting. | |
Chapman et al.; 2016; BMJ Supportive & Palliative Care [31] | Quasi-experimental, quantitative comparative. | 250 Australian palliative care patients spread across 4 residential facilities over a 6-month period. 77 were included in the intervention group. The control group of 173 decedents was retrospective. | To examine the effect of a ‘Palliative Care Needs Rounds’ programme (supporting clinical decision-making, education and training) on hospital utilisation. | The intervention group had on average a shorter length of hospital stay, than those not enrolled in the programme (1.9 vs. 4.8 p = 0.02). No significant difference in number of hospital admissions. | Care home education could decrease the length of hospital stay. | Historical data used for the control group. Some residents were excluded due to incomplete data. |
Kane et al.; 2017; JAMA Internal Medicine [32] | Clustered randomised clinical trial. | 36,717 residents at 85 nursing homes, 33 intervention sites and 52 control sites that had not previously implemented the INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement programme. | To establish whether training and support for implementation of a nursing home quality improvement programme reduce hospitalisations and ED visits. | There was no significant difference between intervention and control nursing homes regarding overall hospital admissions, 30-day readmission rates or emergency department visits that resulted in hospitalisation. Intervention homes showed a 6.5% reduction in overall hospitalisations, and 15% reduction in potentially avoidable hospitalisations compared with the pre-intervention rate amongst intervention homes. | Training and support for INTERACT implementation had no impact on hospitalisation or emergency department visits. | The original sample contained a substantial number of nursing homes that reported prior use of INTERACT. |
2b; palliative care support in the community
Author, date and journal | Study design | Sample and setting | Research focus | Relevant results | Wider implications | Limitations |
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Wong et al.; 2013; Annals, Academy of Medicine, Singapore [38] | Quantitative, prospective cohort study. | 44 Singaporean patients with advanced heart failure enrolled in an Advanced Care Programme between July 2008 and July 2010. | To evaluate the impact of a home-based Advanced Care Programme on healthcare utilisation in the last stages of life for advanced heart-failure patients. | Mean all-cause and heart failure related admissions prior to Advanced Care Programme enrolment were 3.6 and 2.0 episodes. Following admission to the programme, these dropped to 1.0 and 0.6 (p < 0.0001), representing 72 and 70% reductions, respectively. After follow-up duration, adjusted hospital admission episodes were 1.2 and 0.5 (p < 0.0001). | Home-based palliative care has shown reduced hospital utilisation for patients with heart failure. | Small sample size. No control group. Did not account for placebo effects of a palliative programme. |
Lustbader et al.; 2017; Journal of Palliative Medicine [39] | Quantitative, retrospective, comparative analysis. | 82 US Medicare Shared Savings Program accountable care organisation deceased patients compared with 596 patients receiving usual care between October 2014 and March 2016. | To evaluate the impact of a home-based palliative care programme within an accountable care organisation on cost and resource utilisation during the final 3 months of life. | A 34% reduction in hospital admissions during the final month of life was observed in hospital-based palliative care-enrolled patients. Hospital-based palliative care was also linked with a reduction in emergency department visits per 1000 patients compared with standard care (878 vs. 1097). | Hospital-based palliative care in an accountable care organisation is linked with significant cost savings and fewer hospital admissions. | Lack of minority populations. No case-matched control group (although disease burden was quantified and equal for both groups, p = 0.4). |
Spilsbury et al.; 2017; PLOS ONE [40] | Quantitative, retrospective cohort study. | 12,763 Western Australian patients who died from cancer, and 7 from non-cancer conditions. | To investigate how community-based palliative care is associated with a reduction in acute care health service use. | During the intervention period, hospital admissions dropped by 34% and the mean length of stay decreased by 6%. For patients < 70 years, receiving community-based palliative care was linked with a reduced rate of hospital admissions approximately 5 months before death, and in those > 70 years, the reduction was observed up to a year before death. | Hospital admission rates were reduced when patients were receiving community-based palliative care. These effects could be seen within 5 months of death and earlier in older patients. | Lack of detail on intervention intensity. Palliative care may have been different for those living in rural and remote areas. |
Seow et al.; 2014; British Medical Journal [41] | Quantitative, pooled analysis of a retrospective cohort study. | 6218 Canadian cancer patients, of whom 3109 received community-based palliative care administered by one of 11 specialist palliative care teams (intervention)a, and 3109 received standard community-based palliative care during the last 2 weeks of life (control). | To understand the pooled effect of exposure to any one of 11 palliative care teams operating at patients’ homes. | 970 patients from the intervention group visited a hospital, compared with 1219 from the control group (31.2% vs. 39.3%, p < 0.001). 896 patients from the intervention group were admitted to the emergency department, compared with 1070 in the control group (28.9% vs. 34.5% p < 0.001). The pooled relative risks of being admitted to hospital and an emergency department in late life for the intervention versus control group are 0.68 and 0.77, respectively. Fewer intervention patients died in hospital than control patients (503 vs. 887, p < 0.001). | Palliative care teams appear to reduce both hospital and emergency department admission, as well as the amount of hospital deaths. | Propensity scores cannot account for unmeasured variables such as preferred place of death or existing care. Generally, cancer patients only. |
Seow et al.; 2016; Journal of Pain and Symptom Management [42] | Quantitative, retrospective cohort study. | 54,576 Canadian decedents who used home care nursing services during the last 6 months of life. | To explore the link between the home care nursing rate and emergency department visit rate in the following week during the last 6 months of life. | Patients who received the intervention during any week had a 31% lower emergency department visit rate during the following week than did patients receiving standard care. During the last month of life, those receiving home care end-of-life nursing and standard care for more than 5 h per week were associated with a decreased emergency department visit rate of 41 and 32%, respectively, compared with patients with 1 h of standard nursing per week. | There is a temporal association between receiving home-based end-of-life nursing care in a specific week during the last 6 months of life and a reduced emergency department visit rate. Higher levels of both home-based end-of-life care and standard care are also linked with a lower emergency department visit rate. | Study does not imply causality. The database does not hold other important factors which may influence emergency department visit rates. |
Gagnon et al.; 2015; Journal of Pain and Symptom Management [43] | Population study. | 52,316 Canadian cancer patients between 2003 and 2006. 27,255 had received home palliative care services | To test the association between the quality of home palliative care services and quality of end-of-life palliative care indicators. | Increased quality of home palliative care services was associated with a lower proportion of men having 1 or more visit to an emergency department during the last month of life (risk ratio 0.924; 95% CI 0.867–0.985). In women, higher-quality home palliative care services were also associated with a higher proportion of patients dying at home (risk ratio 2.255; 95% CI 1.703–2.984) and spending less time in hospital (risk ratio 0.765; 95% CI 0.692–0.845). | Effective home palliative care services were associated with improved end-of-life palliative care indicators. | Lack of a needs assessment. |
Iupati and Ensor; 2015; Internal Medicine Journal [44] | Retrospective, quantitative study of consecutive patient records over 6 years. | 73 New Zealand-based patients with advanced chronic obstructive pulmonary disease who were referred to 2 community hospice programmes. | To examine the impact of community-based hospice programmes on hospital admission in patients with advanced chronic obstructive pulmonary disease. | Following entry into the hospice programme, a mean decrease of 2.375 hospital admissions over 1 year was observed. | Community-based hospice programmes may be linked with a reduction in hospital admissions in patients with advanced chronic obstructive pulmonary disease. | Highly selected and small sample size. Only 2 regional hospices. |
Rosenwax et al.; 2015; Palliative Medicine [45] | Quantitative, retrospective, population-based cohort study. | All patients in Western Australia who died with dementia between January 2009 and December 2010 (n = 5261) and a comparator of patients who died from other conditions who received palliative care (n = 2685) | To report on the use of hospital emergency departments during the last year of life by patients who died with dementia and the effect that community-based palliative care had upon that use. | The rate of emergency department visits significantly increased if community-based palliative care was not being received, varying over the last year of life. During the initial 130 days, patients who received standard care visited the emergency department 1.4 more times often than those receiving community-based palliative care. In the last month of life, those receiving standard care in a private residence visited the emergency department 6.7 times more frequently and those receiving standard care in a care facility visited emergency department 3.1 times more frequently than those who received community-based palliative care. | Community-based palliative care of people who die with dementia is linked with a significant reduction in emergency department visits during the last year of life. | A retrospective study using data not collected for the purpose of the study. |
Alonso-Babarro et al.; 2013; Palliative Medicine [46] | Quantitative population-based comparison. | 549 cancer patients in 2 areas in the Madrid region. Only 1 area had a palliative home care team. | To explore the impact of palliative home care team in the last 2 months of life on place of death, emergency room visits, admissions and use of hospital resources. | Frequency of patients dying in hospital was significantly lower in the palliative home care team area (61% vs. 77%, p < 0.001), as were the number of patients using emergency services (68% vs. 79%, p = 0.004) and number of patients using in-patient services (66 vs. 76%, p = 0.012). After adjusting for other factors, patients in the palliative home care team area had a lower risk of hospital death than those in the non-palliative home care team area (adjusted odds ratio 0.4, 0.2–0.6). | Suggests that palliative home care team is associated with reduced in-patient deaths and use of hospital services in the last 2 months of life. | Focused on 2 specific urban areas, meaning unidentified factors may influence in-patient deaths. |
McNamara et al.; 2013; Journal of Palliative Medicine [47] | Quantitative, retrospective cross-sectional study. | 746 Australian deceased cancer patients between August 2005 and June 2006. | To investigate whether early entry to community-based palliative care reduces emergency department admissions during the last 90 days of life. | During the final 90 days of life, fewer patients who had early access to palliative care visited an emergency department than did patients without early access (31.3% vs. 52.0%). | Early access to community-based palliative care can reduce the frequency of patients’ emergency department visits. | The data were not originally collected to answer the research question. |
Ranganathan et al.; 2013; Journal of Palliative Medicine [48] | Quantitative, retrospective cohort study. | 391 American palliative home care patients compared with 890 palliative care patients receiving standard care at home, post-acute care programme. | To study the impact of palliative home care on 30-day hospital readmission rates. | Those receiving palliative care at home had a 30-day readmission probability of 9.1% vs. 17.2% in those who received standard care at home. | Compared to regular care at home, palliative home care may reduce 30-day hospital readmission. | The study could not adjust for treatment intensity, which may have affected readmission. |
Cassel et al.; 2016; Journal of the American Geriatric Society [49] | Quantitative, retrospective study using propensity-based matching. | 368 American patients who received a home-based palliative intervention, Transitions, between 2007 and 2014 were propensity matched with 1075 control individuals. The 4 disease types were cancer, chronic obstructive pulmonary disease, heart failure and dementia. | To assess non-clinical outcomes of a home-based palliative care programme. | For all 4 diseases, the number of participants admitted to hospital and the number of hospital days were lower for the Transitions group than the control (p < 0.001). The transitions group also had a lower rate of admission during the final 30 days of life (p < 0.001) and hospital deaths (p < 0.001). The mean 30-day readmission rate was lower in the Transitions group for COPD (p = 0.005), heart failure (p < 0.001) and dementia (p = 0.01), but not for cancer (p = 0.08). | The home-based Transitions programme could reduce hospital utilisation for the 4 included disease types. | Retrospective studies have the potential for selection bias. |
Tan el al; 2016; Palliative medicine [50] | Retrospective cohort study. | 321 Singaporean cancer-diagnosed patients who had an expected prognosis of ≤1 year and were enrolled in an integrated hospice home care programme were compared with 593 patients who were referred to other home hospices. | To evaluate the impact of an integrated hospice home care programme on acute care service usage and on rate of home deaths. | Hospital deaths were significantly lower in programme participants (12.1% vs. 42.7%). The programme group had significantly lower emergency department visits and hospitalisations at 30 days, 60 days and 90 days prior to death. | Integrating acute care and home hospice care could reduce acute care service usage. | Only cancer patients were included. |
Riolfi et al.; 2014; Palliative Medicine [51] | Retrospective cohort study. | 402 patients who died in 2011 of cancer as a primary cause in Veneto region, Italy. | To assess the effectiveness of appropriate palliative home care services in reducing hospital admissions and identify predictive factors in hospitalisations of patients treated at home. | The 39.9% of patients who were enrolled in the palliative care programme were more likely to die at home (53.8% vs. 7.9%), had fewer hospital admissions (0.4 vs. 1.3 admissions) and shorter stays (4.4 vs. 19.6 days) in their last 2 months of life. | The findings indicate that palliative home care teams enable consenting patients to stay at home with reduced hospital usage compared with those not under the care of palliative home care teams. | Variables between the intervention and control groups, such as symptoms and socio-economic status, were not considered. |
Lukas et al.; 2013; Journal of Palliative Medicine [52] | Longitudinal case series. | 369 patients with advanced complex illness referred for home-based palliative consultation in the mid-Atlantic United States. | To evaluate home-based palliative care on hospital outcomes within a fee-for-service environment. | There was a significant reduction in hospital utilisation (number of hospitalisations, total hospital bed days, total costs, variable costs and probability of 30-day readmission). The only exception was no change in the probability of an emergency department visit. | These results suggest a home-based palliative medicine practice may reduce hospital utilisation for patients with advanced, complex illness. | Non-randomised. Only accessed hospital utilisation data from 1 health care network. |
Goldenheim et al.; 2014; Journal of Palliative Medicine [53] | Retrospective cohort study. | 59 patients (19 readmitted within 30 days and 40 controls not readmitted) aged ≥65 years who were newly discharged to home hospice care between February 2005 and January 2010. | To identify factors associated with 30-day readmission among older adults newly discharged to hospice. | 25% of admitted patients received a palliative care consultation, compared with 47% of patients who were not readmitted. | Patients discharged to hospice and readmitted within 30 days were less likely to have palliative care consultations. | Small sample and selection bias. |
Kerr et al.; 2014; Journal of Palliative Medicine [54] | Prospective, observational database study. | 149 decedents who received the home care programme. The control population (n = 537) was derived using propensity score matching. | To evaluate the impact on healthcare costs and utilisation of an innovative home-based palliative care programme implemented through a hospice-private payer collaboration. | Home care patients had much lower hospital admission rates, particularly in the last 6 months of life. There was no significant difference in emergency department use between home care patients and those in the control group. | Palliative care programs partnered with community hospice providers may achieve cost savings while providing care across the continuum. | Selection bias. Statistically significant differences in diagnoses and disease types between the control and intervention groups. |
Pouliot et al.; 2017; American Journal of Hospice and Palliative Care [55] | Prospective cohort study. | 123 participants with serious illness enrolled in a programme in New York. | To evaluate the effectiveness of Care Choices, a new in-home palliative care service. | The group had fewer emergency department visits (p < 0.001) and inpatient stays (p < 0.001)) after enrolment in the intervention. | An in-home palliative care programme may be a successful model that satisfies patients’ desire to remain at home and avoid hospital admissions. | Observational results and no randomisation. |
2c; out-of-hours telephone line
Author, date and journal | Study design | Sample and setting | Research focus | Relevant results | Wider implications | Limitations |
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Sue Ryder; 2012; Partnership for Excellence in Palliative Support (PEPS) [27] | Longitudinal pilot study. | PEPS is a single-point-of-access, 24-h telephone service in Bedfordshire, England, which brings together 15 organisations. A senior nurse is the first point of access. | To compare information from a sample of patients with hospital activity datasets before and after registration. | 1051 patients were registered. 68% who died were supported to die at home, with only 10% dying in an acute hospital. | Data suggested that introduction of a single point of access service could result in 30% fewer admissions, a 30% shorter stay and a cost reduction of around £300 per admission. | Pilot project. |
Lustbader et al.; 2017; Journal of Palliative Medicine [39] | Quantitative, retrospective, comparative analysis. | 82 US Medicare Shared Savings Program accountable care organisation deceased patients compared with 596 patients receiving usual care between October 2014 and March 2016. | To evaluate the impact of a home-based palliative care programme that included a 24/7 telephone line. | A 34% reduction in hospital admissions during the final month of life was observed in hospital-based palliative care-enrolled patients. Hospital-based palliative care was also linked with a reduction in emergency department visits per 1000 patients compared with standard care (878 vs. 1097). | Hospital-based palliative care in an accountable care organisation is linked with significant cost savings and fewer hospital admissions. | Did not test for the individual benefits or drawbacks of a 24/7 telephone line in this setting. |
Alonso-Babarro et al.; 2013; Palliative Medicine [46] | Quantitative population-based comparison. | 549 cancer patients in 2 areas in the Madrid region. Only 1 area had a palliative home care team. | To explore the impact of palliative home care team in the last 2 months of life on place of death, emergency room visits, admissions and use of hospital resources. | Frequency of patients dying in hospital was significantly lower in the palliative home care team area (61% vs. 77%, p < 0.001), as were the number of patients using emergency services (68% vs. 79%, p = 0.004) and number of patients using in-patient services (66 vs. 76%, p = 0.012). After adjusting for other factors, patients in the palliative home care team area had a lower risk of hospital death than those in the non-palliative home care team area (adjusted odds ratio 0.4, 0.2–0.6). | Suggests that palliative home care team is associated with reduced in-patient deaths and use of hospital services in the last 2 months of life. | Focused on 2 specific urban areas, meaning unidentified factors may influence in-patient deaths. |
Ranganathan et al.; 2013; Journal of Palliative Medicine [48] | Quantitative, retrospective cohort study. | 391 American palliative home care patients compared with 890 palliative care patients receiving standard care at home, post-acute care programme. | To study the impact of palliative home care with a 24-h telephone line on 30-day hospital readmission rates. | Those enrolled in the palliative care at home programme had a 30-day readmission probability of 9.1% vs. 17.2% in those who received standard care at home. | Palliative home care programmes with an out-of-hours telephone line may help reduce 30-day hospital admission rates. | Did not individually test the effect of the telephone line. The study could not adjust for treatment intensity, which may have affected readmission. |
Purdy et al.; 2015; BMJ Supportive & Palliative Care [56] | Quantitative, retrospective cohort study. | 3564 patients who died of end-of-life conditions in North Somerset and Somerset. 829 patients used the Delivering Choice Programme, a palliative care service with an out-of-hours telephone line, front-of- house, hospital-based, end-of-life-care discharge-in-reach nurses and end-of-life care coordination centres. | To investigate the effect of the delivering choice programme on place of death and hospital utilisation. | The phone line was associated with a lower risk of hospital admission during the last week of life only (OR 0.44, 95% CL 0.25–0.78, p = 0.005). There was also a risk reduction of emergency department attendance in the last week of life linked with the phone line (OR 0.34, 95% CL 0.17–0.70, p = 0.003). | Out-of-hours telephone lines may reduce hospital utilisation close to death. | No randomisation. Did not adjust for comorbidities. Selection bias. |
2d; telemedicine/teleconsultation
Author, date and journal | Study design | Sample and setting | Research focus | Relevant results | Wider implications | Limitations |
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Hex et al.; 2018; Economic analysis of care homes: New Models of Care Vanguard [36] | Longitudinal cohort study. | 141 care homes that had a telemedicine programme were compared with 25 control care homes in the north of England. | To quantify the economic benefits generated by a telemedicine programme 1 year after implementation. | Emergency department admissions decreased in the care homes using telemedicine by 4% and increased in the control homes by 7%. Of the intervention homes, nursing homes saw a 13% decrease in emergency admission and residential homes saw a 6% increase. Low intervention home usage was associated with a 17% reduction in emergency admissions, whilst high usage of homes was associated with a 10% increase. | The findings were not statistically significant and can only be taken at face value. | Limited control group. Extensive data cleaning was needed to produce useable data. The intervention was rolled out over time so there was no universal start date. |
Grabowski et al.; 2014; Health Affairs [37] | Prospective observational study. | A chain of care homes in Massachusetts introduced telemedicine in 11 homes, covering weekday evenings and weekends. | To establish whether the lack of a physician’s presence at homes out of hours might contribute to inappropriate hospitalisations and whether switching to an on-call telemedicine physician could reduce inappropriate hospital admissions. | Both intervention and control groups saw a decline in hospitalisations, of 9.7 and 5.3%, respectively. When looking at more and less engaged homes, a significant decline in hospitalisations (11.3%) was found at more engaged care homes. | The findings suggest that nursing homes fully engaged in out-of-hours telemedicine could see a reduction in hospitalisations. | Small sample. |
Lustbader et al.; 2017; Journal of Palliative Medicine [39] | Quantitative, retrospective, comparative analysis . | 82 US Medicare Shared Savings Program accountable care organisation deceased patients compared with 596 patients receiving usual care between October 2014 and March 2016. | To evaluate the impact of a home-based palliative care programme within an accountable care organisation on cost and resource utilisation during the final 3 months of life. | A 34% reduction in hospital admissions during the final month of life was observed in hospital-based palliative care-enrolled patients. Hospital-based palliative care was also linked with a reduction in emergency department visits per 1000 patients compared with standard care (878 vs. 1097). | Hospital-based palliative care in an accountable care organisation is linked with significant cost savings and fewer hospital admissions. | Did not test for the individual benefits or drawbacks of a 24/7 telephone line in this setting. |
Hoek et al.; 2017; BMC Medicine [57] | Two-armed, non-blinded randomised control trial. | 74 Dutch home-dwelling palliative care cancer patients between May 2011 and January 2015. Patients were randomised to either an intervention group that received weekly teleconsultations or a control group that received standard care for 12 weeks. | To determine the effects of weekly teleconsultations on hospital admissions for palliative patients (secondary objective). | The was no significant difference in mean hospital admissions between the intervention and control groups (0.47 vs. 0.38, p = 0.60). | Suggests that weekly teleconsultations do not reduce hospital admissions for palliative patients. | Some patients eligible for the trial were not approached due to clinical considerations, which may have caused selection bias. High attrition rate. |
Bakitas el; 2015; Journal of Clinical Oncology [58] | Two arm randomised study | 207 patients with advanced cancer attending a National Cancer Institute Center, a Veterans Affairs Medical Centre and community outreach clinics were randomly assigned to early or late intervention. | Intervention included an in-person palliative care consultation, telehealth nurse coaching sessions and monthly follow-up. Outcomes were quality of life, symptom impact, mood, one-year survival and resource use (hospital/intensive care days, emergency room visits and death location. | Overall patient-reported outcomes were not statistically significant after enrolment or before death. Kaplan-Meier one-year survival rates were 63% in the early group and 48% in the delayed group (p = 0.038). Relative rates of early to delayed decedents’ resource use were similar for hospital days, intensive care days, emergency room visits and home deaths. | Early-entry participants’ patient-reported outcomes and resource use were not statistically different; however, their survival 1 year after enrolment was improved compared with those who began 3 months later | Heterogeneity and differences in unmeasured characteristics could limit practical application. Results reflect a New England population. Half of patients in the delayed group were referred for palliative care consultation ahead of time. Not all patients completed all interventions. |
2e; ambulance and paramedic education
2f; integrated palliative care models
Author, date and journal | Study design | Sample and setting | Research focus | Relevant results | Wider implications | Limitations |
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Ferrell et al.; 2015; Journal of Pain and Symptom Management [60] | Prospective, quasi-experimental. | 544 American patients with Stage I–IV non-small cell lung cancer were enrolled in the study. The intervention group (n = 272) were reviewed at integrated care meetings. The control group received standard care (n = 219). | To test the effectiveness of an integrated palliative programme for cancer patients. Outcome measures included QoL, symptoms, distress and hospital utilisation. | There were no statistically significant differences in unscheduled hospital admissions between the groups in the last 2 weeks of life. | Integrated palliative may not reduce hospital admissions | The sequential design may have resulted in temporal bias. This design did not allow for establishing the exact element of the intervention that was successful. |
Benthien et al.; 2018; Journal of Pain and Symptom Management [61] | Randomised controlled trial with a 1:1 ratio. | 340 Danish in- and out- cancer patients were assigned to either an intervention or control group. The intervention group received standard care plus specialised palliative care enriched with a standardised psychological intervention for patients and caregivers at home, and the control group received standard care only. | To investigate whether a transition process from oncological treatment to specialist palliative care at home for patients with incurable cancer results in more patients reaching their preferred place of care and death. | The intervention group had more hospital admissions due to health deterioration (22% vs. 16%, p = 0.04) or an unmanageable home situation (8% vs. 4%, p = 0.0119). Hospital admissions were most often caused by symptoms without progression in the intervention group (11% vs. 7%, p = 0.0493). There was no significant difference in overall potentially avoidable admissions. Both groups felt generally safe regarding their place of care. | This type of intervention may not decrease hospital admissions in incurable cancer patients. It may be more successful for those with a slower declining rate of health and with better diagnostics at home to rule out emergencies in need of hospital admission. | Two-thirds of the control group received specialist palliative care, albeit considerably later than the intervention group. Lack of a consistent definition of potentially avoidable admissions. |
Blackhall et al.; 2016; Journal of Palliative Medicine [62] | Retrospective electronic records review. | 207 US patients with advanced cancer were referred to the Comprehensive Assessment with Rapid Evaluation and Treatment (CARE) Track palliative care intervention was compared with 198 deceased patients with similar diagnoses who were not. | To measure the time of referral to outpatient palliative and impact on end-of-life care for patients with cancer. | CARE Track patients had fewer end of life hospitalisations, were less likely to die in hospital and had increased hospice utilisation and decreased costs of care. | Referral to outpatient palliative care within 3 months of death improved end of life care and may reduce costs. However, many patients were not referred, and systematic methods of referrals are needed. | Non-randomised and single centre with a predominantly white population. Selection bias. Significant differences between control and intervention groups such as age and gender. |
Jang et al.; 2015; Journal of the National Cancer Institute [63] | Retrospective cohort study. | 5381 patients who died of advanced pancreatic cancer between January 2005 and March 2011 in Ontario, Canada. Approximately half had received a palliative care consultation. | To evaluate the impact of palliative care, including intensity, on the aggressiveness of care near death in patients with advanced pancreatic cancer. | Patients who received a palliative care consultation had lower frequencies of intensive care unit visits near death (1.1% vs. 7.8%), multiple emergency department visits (7.4% vs. 28.5%) and multiple hospitalisations (3.8% vs. 12.8%). | Palliative care is associated with less aggressive care near death. | Selection bias and lack of control of confounding variables due to observational design. |
Morita et al.; 2013; Lancet Oncology [64] | Mixed-methods study. | A multifaceted programme of interventions for patients with cancer was introduced in 4 regions of Japan. Place of death was compared before (5146 decedents) and after the interventions (5546 decedents). | To assess the impact of these interventions on numbers of home deaths, coverage of specialist services and patient-reported and family-reported quality of care. | Proportions of home deaths increased significantly, from 6.76% before the intervention compared with 10.48% after intervention. | A regional programme of interventions could improve the quality of palliative care. | The data used may not be fully representative of the region. |
Youens et al.; 2017; Journal of Palliative Medicine [65] | Retrospective, observational cohort study. | 28,561 West Australian cancer decedents from 2001 to 2011, of which 16,530 accessed a community-based palliative care intervention. | To compare place of death and acute care hospital use in the last year of life between cancer decedents who did and did not access a community-based palliative service. | Intervention users had 3 times greater odds of dying outside of hospital than non-users. Intervention users had fewer unplanned hospital admissions and emergency department admissions in the last year/last week of life. Those who accessed the service had significantly shorter hospital stays than the control group. | The palliative care community service supported people to die outside of hospital and was associated with reduced acute care admissions, bed days and costs over the last year of life. | Limited ability to establish causation due to it being an observational study. Lack of data on symptom severity and functional status, which may have differed between groups. |
May et al.; 2017; Palliative Medicine [66] | Prospective cohort study. | 863 adults with advanced cancer admitted to 3 US hospitals. Usual care (n = 637), early palliative care (n = 177) and late palliative care (n = 49) were compared. | To establish the association between early palliative care consultation team intervention and 1) intensity of service and length of stay compared with usual care; and 2) day-to-day costs compared with a later intervention. | Early palliative care patients had shorter hospital stays than late palliative care patients (mean length of stay 6.7 vs. 13.6 days). Early palliative care patients had shorter stays than usual care patients (mean length of stay 6.7 vs. 7.8 days). | Reducing the length of stay is the biggest cost saver in early consultation for patients with advanced cancer. | Lack of control over confounding variables due to its observational design. |
Rogers et al.; 2017; Journal of the American College of Cardiology [67] | Randomised controlled trial. | 150 patients with advanced heart failure received standard care (n = 75) or standard care plus a palliative care intervention (n = 75) at a single centre. | To investigate whether an integrated palliative care intervention improves certain outcomes in heart failure care. | Randomisation to the intervention did not affect hospitalisation or mortality. | The single centre and intervention care was implemented by a single nurse. The control group may have received palliative care not representative of standard care. | |
Brannstrom et al.; 2014; European Journal of Heart Failure [68] | Randomised controlled study. | 36 Swedish patients with chronic heart failure were randomised to PREFER and compared with 36 patients in a control group. | To compare the outcomes of PREFER with regard to patient symptoms, quality of life and hospitalisations with those of usual care. | The mean number of hospitalisations was significantly lower in the PREFER group (0.42 vs. 1.47). The total number of hospitalisations was lower in the PREFER group (15 vs. 53). The mean number of days spent in hospital was significantly lower in the PREFER group than in the control group (2.9 vs. 12.4). | Person-centred care combined with active heart failure and palliative care at home has the potential to improve quality of life and morbidity substantially in patients with severe chronic heart failure. | Intervention participants were significantly older than control group participants. The study was small and at a single centre. |
Chan et al.; 2014; Journal of Pain and Symptom Management [69] | Prospective, longitudinal, observational study. | 19 patients with end-stage renal disease who attended a renal palliative care clinic and had more than 1 emergency department visit in 3 months. Follow-up was more frequent and intensified. | To assess whether intensified and more frequent follow-up visits affected the rate of renal palliative care clinic attendance, emergency department attendance and hospital admission. | The rate of emergency department attendance (2.63 vs. 0.63) and acute hospital admission (1.59 vs. 0.58) was significantly reduced after intensified follow-up. Clinic attendance rates improved from 56 to 85%. | Intensifying renal palliative care follow-up minimised the utilisation of acute medical services and improved outpatient attendance at the renal palliative care clinic. | Small sample, selection bias. Data originally collected for a different purpose. |
Horton et al.; 2013; Journal of Palliative Medicine [70] | Single-centre cohort, longitudinal, observational study | 30 patients with advanced chronic obstructive pulmonary disease and 18 caregivers were followed in their home for 6 months whilst participating in an education programme followed by home-based palliative care. | To determine the feasibility of 1) implementing a customised home-based palliative care service for patients and caregivers living with advanced chronic obstructive pulmonary disease; and 2) measuring outcomes of providing such services. | 25 patients and 14 caregivers enrolled in the home-based palliative care after completing the education programme. 12/17 patients who chose home as their preferred place of death. None of the deaths occurred at home. A drop in hospital utilisation was observed in the first 100 patients before vs. after enrolment. | Providing home-based palliative care for patients with advanced chronic obstructive pulmonary disease is feasible but requires further study to fulfil their place-of-death preference. | Lack of standardisation of the intervention across participants and selection bias. |
Hussain et al.; 2013; International Journal of Palliative Nursing [71] | Retrospective study. | Participation in a nurse-led palliative neurology service in the North of England was offered to 62 patients. Outcomes were compared with standard National End of Life Care Programme care | To assess the key outcomes of a UK nurse-led palliative neurology service against standard National End of Life Care Programme standards. | Mean hospital admissions in the intervention group were 0.9 vs. 3.5 nationally across all diagnoses. 26% of patients receiving the intervention died in hospital vs. 46% nationally. | The service model fulfilled key standard National End of Life Care Programme recommendations and resulted in low hospital admissions and deaths. | Small sample. No control group. |
Wu et al.; 2013; Journal of Palliative Medicine [72] | Retrospective cohort study. | 50 US patients who received a palliative care consultation in the emergency department before hospital admission were compared with 1385 patients who received a palliative care consultation after admission to hospital. | To see whether inpatient admissions after palliative care initiated in the emergency department were associated with shorter length of stay than in patients whose palliative care was initiated after hospital admission. | Length of stay was reduced by 3.6 in patients who received palliative care consultation prior to admission. | Early initiation of palliative care in the emergency department resulted in shorter inpatient stays. | Non-randomised and selection bias. |
Desrosiers et al.; 2014; Journal of Pain and Symptom Management [73] | Retrospective cohort study. | 56 consecutive deaths under a new service at a hospital in Cape Town, South Africa, were compared with 48 consecutive deaths immediately before implementation of the new service. | To assess whether a hospital-based palliative care service reduces admissions and increases home death rates. | The mean number of admissions for the intervention group and control groups were 1.39 vs. 1.98. The mean total number of hospital days for the intervention and control groups were 4.52 vs. 9.3. 58.9% of the intervention group died at home, compared with 18.8% of the control group. | An outpatient hospital-based service reduced admissions and improved the chance of home death, offering a feasible and cost-effective model for such settings. | Selection bias. |